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 D

Explanation

A. The stoma protrudes slightly from the abdomen: A stoma that protrudes slightly (about 1–2 cm) above the skin surface is normal and indicates healthy placement. This finding does not require reporting.

B. The stoma bleeds lightly when touched: Light bleeding with gentle palpation or cleaning is common due to the stoma’s rich blood supply and is generally not concerning unless bleeding is excessive.

C. The stoma is draining a small amount of liquid stool: Liquid stool drainage is expected from a colostomy, especially in the early postoperative period. This is a normal finding that does not require reporting.

D. The stoma appears dark in color: A dark, dusky, or black stoma indicates compromised blood flow and possible ischemia or necrosis. This is a serious finding that requires immediate reporting to prevent further complications.

A. Goggles B. Gloves C. Mask D. Gown

Correct Answer is B

Explanation

A. Goggles: Goggles protect the eyes from splashes and should be removed after gloves and gown, once the risk of contamination is lower. Removing them too early can increase the risk of contamination if hands are still contaminated.

B. Gloves: Gloves are the most contaminated item after wound care and should be removed first to prevent spreading microorganisms to other personal protective equipment or the nurse’s skin. Proper glove removal technique reduces the risk of self-contamination.

C. Mask: Masks protect the respiratory tract and are typically removed last, after gloves, gown, and goggles, to maintain protection as long as possible. Removing the mask too early can expose the nurse to airborne particles.

D. Gown: The gown is removed after gloves because it is also contaminated but less so than gloves. Removing gloves first minimizes transferring contaminants from the gloves to the gown or other surfaces during removal.

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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

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