Health and Physical Assessment of the Adult Client

A Spanish-speaking client arrives at the triage desk in the emergency department and states to the nurse that an interpreter is needed. Which is the best action for the nurse to take?

The nurse is performing a neurological assessment on a client and notes a positive Romberg’s test. The nurse makes this determination based on which observation?

The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment of the client, the nurse should expect to note which finding?

A client diagnosed with conductive hearing loss asks the nurse to explain the cause of the hearing problem. The nurse plans to explain to the client that this condition is caused by which problem?

While performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscultates a murmur. The nurse documents the finding and describes the sound as which?

The nurse is testing the extraocular movements in a client to assess for muscle weakness in the eyes. The nurse should implement which assessment technique to assess for muscle weakness in the eye?

The nurse is instructing a client how to perform a testicular self-examination (TSE). The nurse should explain that which is the best time to perform this exam?

The nurse is assessing a client suspected of having meningitis for meningeal irritation and elicits a positive Brudzinski’s sign. Which finding did the nurse observe?

A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds should the nurse expect to hear when performing a respiratory assessment on this client?

The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of assessment? Select all that apply.

1. Auscultating lung sounds
2. Obtaining the client’s temperature
3. Assessing the strength of peripheral pulses
4. Obtaining information about the client’s respirations
5. Performing a musculoskeletal and neurological examination
6. Asking the client about a family history of any illness or disease