Page 409 - Saunders Comprehensive Review For NCLEX-RN

client?
1. Stridor
2. Crackles
3. Wheezes
4. Diminished
99. 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

Answers

90. Answer: 3

Rationale: The best action is to have a professional hospital-based interpreter
translate for the client. English-speaking family members may not appropriately
understand what is asked of them and may paraphrase what the client is actually
saying. Also, client confidentiality as well as accurate information may be
compromised when a family member or a non–health care provider acts as
interpreter.
Test-Taking Strategy: Note the strategic word, best. Initially focus on what the
client needs. In this case the client needs and asks for an interpreter. Next keep in
mind the issue of confidentiality and making sure that information is obtained in the
most efficient and accurate way. This will assist in eliminating options 1, 2, and 4.
Level of Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Content Area: Foundations of Care: Communication
Health Problem: N/A
Priority Concepts: Communication; Culture
Reference: Lewis et al. (2017), p. 31.

91. Answer: 3

Rationale: In Romberg’s test, the client is asked to stand with the feet together and
the arms at the sides, and to close the eyes and hold the position; normally the client
can maintain posture and balance. A positive Romberg’s sign is a vestibular

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