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
... [Show More] 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 side, 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
A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed
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?
Rhythmic respirations with periods of apnea
Regular rapid and deep, sustained respirations
Totally irregular respiration in rhythm and depth
Irregular respirations with pauses at the end of inspiration and expiration
Rhythmic respirations with periods of apnea
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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
A physical obstruction to the transmission of sound waves
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
A blowing or swooshing noise
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?
Test the corneal reflexes.
Test the 6 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.
Test the 6 cardinal positions of gaze.
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?
After a shower or bath
While standing to void
After having a bowel movement
While lying in bed before arising
After a shower or bath
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?
The client rigidly extends the arms with pronated forearms and plantar flexion of the feet.
The client flexes a leg at the hip and knee and reports pain in the vertebral column when the leg is extended.
The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column.
The client's upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated.
The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column.
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?
Stridor
Crackles
Wheezes
Diminished
Wheezes
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.
Auscultating lung sounds
Obtaining the client's temperature
Assessing the strength of peripheral pulses
Obtaining information about the client's respirations
Performing a musculoskeletal and neurological examination
Asking the client about a family history of any illness or disease
Auscultating lung sounds
Obtaining the client's temperature
Obtaining information about the client's respirations
The nurse is instructing a client to perform a testicular self-examination (TSE). The nurse should provide the client with which information about the procedure?
To examine the testicles while lying down
That the best time for the examination is after a shower
To gently feel the testicle with one finger to feel for a growth
That TSEs should be done at least every 6 months
That the best time for the examination is after a shower [Show Less]