A nurse in a provider's office is collecting data from a client. Which of the following actions should the nurse take to check the client's balance? (Select all that apply.)

Have the client perform heel-to-toe walking.

Perform Weber's test.

Check for a positive Babinski reflex.

Perform the Romberg test.

Have the client lie in bed and use his heel to draw a line on the opposite shin.

Answer and Explanation

Correct Answer : A,D,E

A. Have the client perform heel-to-toe walking: Heel-to-toe walking (tandem gait) assesses balance and coordination by challenging the client’s ability to maintain stability during a narrow base of support. Difficulty with this test can indicate problems with cerebellar function or proprioception, which are essential for balance.

B. Perform Weber’s test: Weber’s test evaluates hearing by assessing bone conduction and is not related to balance assessment. It helps differentiate between conductive and sensorineural hearing loss but does not provide information about vestibular function.

C. Check for a positive Babinski reflex: Babinski reflex testing assesses neurological function of the corticospinal tract but does not evaluate balance. A positive Babinski indicates upper motor neuron damage but is unrelated to equilibrium or postural control.

D. Perform the Romberg test: The Romberg test evaluates proprioception and balance by assessing the client’s ability to maintain standing posture with eyes closed. A positive Romberg sign suggests impaired proprioception or vestibular dysfunction affecting balance.

E. Have the client lie in bed and use his heel to draw a line on the opposite shin: This test evaluates coordination and proprioception, important components of balance, by assessing precise lower limb control. Difficulty performing this task may indicate issues with neuromuscular control or proprioception.

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Correct Answer is C

Explanation

A. Ask the assistive personnel to document the client's time of death: Documenting the time of death is a critical nursing responsibility and should be done by the nurse or healthcare provider, not delegated to assistive personnel. Accurate documentation is essential for legal and medical records, especially when an autopsy is planned.

B. Wear sterile gloves when cleaning the client's body: Sterile gloves are not necessary for routine postmortem care; clean gloves are sufficient. Sterile gloves are reserved for invasive procedures to prevent infection, whereas postmortem care focuses on hygiene and respect for the deceased.

C. Place an identification tag on the outside of the client's shroud: Proper identification of the deceased is crucial, especially when an autopsy is required. Placing an identification tag on the shroud ensures correct identification during transport and handling, preventing misidentification and maintaining respect for the client.

D. Remove the client's dentures and give them to the client's family: Dentures should typically remain in the client's mouth during postmortem care to preserve facial structure and appearance. Removing them can alter the deceased’s appearance, which may be distressing to the family and is generally avoided unless specifically requested.

A. Check the client's gastric residual. B. Verify the tube placement. C. Pour the medication into the syringe and allow it to flow by gravity. D. Clamp the NG tube for 20 to 30 min.

Correct Answer is ["B","A","C","D"]

Explanation

A. Check the client's gastric residual: After confirming tube placement, gastric residual is assessed to evaluate delayed gastric emptying, which could increase the risk of aspiration. This is done before administering medications or feedings.

B. Verify the tube placement: Tube placement is verified first to ensure the medication is delivered into the stomach and not the lungs. This prevents aspiration and other complications associated with incorrect tube placement.

C. Pour the medication into the syringe and allow it to flow by gravity: Once placement is confirmed and residual checked, the medication is administered via gravity through the syringe to minimize pressure on the NG tube and promote safe delivery.

D. Clamp the NG tube for 20 to 30 min: After administering the medication, the NG tube is clamped to allow for medication absorption before suction is resumed. Immediate suctioning would remove the medication before it can take effect.

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A nurse in a provider's office is collecting data from a client. Which of the following actions should the nurse take to check the client's balance? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning to provide postmortem care for a client who requires an autopsy. Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

Correct Answer is ["B","A","C","D"]

Explanation

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