A nurse and an assistive personnel (AP) are providing postmortem care for a deceased client before visitation by the family. Which of the following actions by the AP requires intervention by the nurse?

Gathering the client's personal belongings.

Removing the client's dentures.

Placing absorbent pads under the client's buttocks.

Closing the client's eyes.

Answer and Explanation

The Correct Answer is B

The correct answer is choice B. Removing the client's dentures.

Choice A rationale:

Gathering the client's personal belongings is an appropriate action in the postmortem care process. This step allows the family to receive their loved one's belongings, contributing to a compassionate and respectful care process.

Choice B rationale:

Removing the client's dentures requires intervention by the nurse. In postmortem care, dentures should be left in place to maintain the natural appearance of the deceased's face and to ensure that the mouth and lips maintain their proper form.

Choice C rationale:

Placing absorbent pads under the client's buttocks is a common practice to manage any potential leakage of bodily fluids after death. This action helps maintain the cleanliness and dignity of the deceased individual.

Choice D rationale:

Closing the client's eyes is an appropriate action during postmortem care. It provides a peaceful appearance and shows respect for the deceased person.

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Correct Answer is A

Explanation

The correct answer is choice A: "Stand with your feet together and your arms at your sides."

Choice A rationale:

This statement is correct. The nurse should instruct the client to stand with their feet together and their arms at their sides for a Romberg test. This position helps to assess the client's ability to maintain balance with minimal sensory input, evaluating their proprioception and vestibular function.

Choice B rationale:

The instruction about the tuning fork is unrelated to the Romberg test. The tuning fork is commonly used to assess hearing and vibratory sensations, not balance.

Choice C rationale:

This statement is unrelated to the Romberg test. Mentioning the lateral side of the foot suggests a neurological examination related to assessing reflexes, such as the Babinski reflex.

Choice D rationale:

This instruction pertains to a different test known as the "finger-to-nose" test, which is used to assess coordination, not balance.

A. Flex the client's feet using pillows. B. Support the client's feet with foot boots. C. Place a hand roll under the client's heels. D. Remove ankle-foot orthotic devices at bedtime.

Correct Answer is B

Explanation

The correct answer is choice B: "Support the client's feet with foot boots."

Choice A rationale:

Flexing the client's feet using pillows might not be sufficient to prevent foot drop. Foot drop is a condition where the client is unable to dorsiflex their foot, and using pillows alone may not provide adequate support to prevent this condition.

Choice B rationale:

Supporting the client's feet with foot boots is the most appropriate intervention to prevent foot drop due to immobility. Foot boots are specifically designed to hold the foot in a dorsiflexed position, preventing the calf muscles from tightening and causing foot drop.

Choice C rationale:

Placing a hand roll under the client's heels might offer some relief, but it's not the most effective intervention for preventing foot drop. Hand rolls are generally used to prevent footdrop by keeping the ankles in a neutral position, rather than solely supporting the heels.

Choice D rationale:

Removing ankle-foot orthotic devices at bedtime is not recommended if the client is at risk for developing foot drop. Ankle-foot orthotic devices are designed to provide continuous support to the feet and prevent muscle contractures. Removing them at bedtime could compromise the effectiveness of the intervention.

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A nurse and an assistive personnel (AP) are providing postmortem care for a deceased client before visitation by the family. Which of the following actions by the AP requires intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing a client for a Romberg test. Which of the following statements should the nurse make?

Correct Answer is A

Explanation

A nurse is contributing to the plan of care for a client who is at risk for developing foot drop due to immobility. Which of the following interventions should the nurse recommend to include in the plan?

Correct Answer is B

Explanation

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