A nurse is assisting in the care of a client who is scheduled for an appendectomy.

Exhibits

The nurse is assisting with preparing the client for surgery. Select the 3 findings that require follow-up prior to surgery.

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.

A. Decrease background noise: Reducing ambient noise helps clients with hearing loss focus better on the speaker’s voice, minimizing distractions and enhancing their ability to interpret sounds or speech through residual hearing or lip-reading.

B. Speak in a loud voice: Speaking loudly can distort speech sounds and facial expressions, making it harder for clients to understand. It’s more effective to speak clearly at a moderate pace and volume.

C. Use short phrases: While shorter phrases might seem easier to process, effective communication often depends on clear context and full sentences. Using natural language helps convey meaning more accurately.

D. Talk at a rapid rate: Rapid speech can be difficult for individuals with hearing loss to follow, especially if they rely on lip-reading. Slower, clearer speech improves understanding and facilitates better communication.