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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Free Nursing Study Resources

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

Explanation

A. Put on a gown: The gown is applied first to prevent contamination of the nurse’s clothing and skin. It acts as the foundational barrier and should be secured at the neck and waist to ensure full coverage before other PPE is donned.

B. Don a mask: The mask is put on second to protect the respiratory tract from airborne or droplet contaminants. Proper placement over the nose and mouth is essential before entering the client’s room to reduce inhalation of infectious particles.

C. Put on goggles: Goggles or a face shield are worn next to shield the eyes from splashes or sprays of infectious material. Since the eyes are a mucous membrane, they must be protected after covering the mouth and nose.

D. Don gloves: Gloves are put on last and should cover the cuffs of the gown to ensure a complete barrier. This final step helps prevent the transmission of pathogens via the hands when interacting with the client or the environment.

A. Brittle hair B. Yellow conjunctivae C. Bradycardia D. Clubbing of the fingernails

Correct Answer is A

Explanation

A. Brittle hair: Malnutrition often leads to protein and micronutrient deficiencies, which impair hair growth and texture, resulting in dry, brittle, or thinning hair. This is a common visible sign in clients with poor nutritional status.

B. Yellow conjunctivae: Yellowing of the conjunctivae typically indicates jaundice due to liver dysfunction or hemolysis, not malnutrition from inflammatory bowel disease. It reflects bilirubin accumulation rather than nutrient deficiency.

C. Bradycardia: While bradycardia may occur in severe starvation or electrolyte imbalance, it is not a consistent or early indicator of malnutrition from inflammatory bowel disease. It requires further context to be clinically relevant.

D. Clubbing of the fingernails: Clubbing is associated with chronic hypoxia or pulmonary/cardiac conditions. It is not commonly linked to malnutrition or inflammatory bowel disease unless there are severe complications such as chronic anemia or hypoxia.

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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

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

Explanation

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Correct Answer is A

Explanation

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