Health Assessment Quiz

A client who does not speak English 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?

• Have one of the client’s family members interpret.

• Page an interpreter from the hospital’s interpreter services.

• Have the triage receptionist who speaks the client’s language interpret.

• Obtain a translation dictionary in the client’s language and attempt to triage the client.

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?

• An involuntary rhythmic, rapid twitching of the eyeballs

• A dorsiflexion of the great toe with fanning of the other toes

• A significant sway when the client stands erect with feet together, arms at the sides, and the eyes closed

• A lack of normal sense of position when the client is unable to return extended fingers to a point of reference

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

• Periods of apnea alternating with periods of deep, rapid breathing

• Constant rapid, shallow breathing

• Irregular, unpredictable breathing with no pattern

• Slow, regular breathing with occasional sighs

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?

• A defect in the cochlea

• A defect in cranial nerve VIII

• A physical obstruction to the transmission of sound waves

• A defect in the sensory fibers that lead to the cerebral cortex

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?

• Lub-dub sounds

• Scratchy, leathery heart noise

• A blowing or swooshing noise

• Abrupt, high-pitched snapping noise

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

• Test the corneal reflexes.

• Test the six cardinal positions of gaze.

• Test visual acuity, using a Snellen eye chart.

• Test sensory function by asking the client to close the eyes and then lightly touching the forehead, cheeks, and chin.

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

• After a shower or bath

• While standing to void

• After having a bowel movement

• While lying in bed before arising

8. 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?

• Flexion of the hips and knees when the neck is flexed

• Pain in the calf upon dorsiflexion of the foot

• Inability to extend the knee when the hip is flexed at 90 degrees

• Stiffness of the neck when trying to touch the chin to the chest

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

• Stridor

• Crackles

• Wheezes

• Diminished

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 would the nurse include for this type of assessment? Select all that apply.

• Auscultating lung sounds

• Obtaining the client’s temperature

• Assessing the strength of peripheral pulses

• Obtaining information about the client's respirations

• Asking the client about a family history of any illness or disease