A nurse is caring for a client who has suspected clonus. Which of the following actions should the nurse take to assess for this condition?

Use a reflex hammer.

Administer magnesium sulfate.

Perform a Romberg test.

Test the gait for symmetry.

Answer and Explanation

The Correct Answer is A

A. Use a reflex hammer: Clonus is assessed by using a reflex hammer to test deep tendon reflexes, typically at the ankle joint. Sustained rhythmic contractions following dorsiflexion of the foot confirm the presence of clonus, which often indicates upper motor neuron dysfunction.

B. Administer magnesium sulfate: Magnesium sulfate is a treatment used in conditions such as preeclampsia with severe features but is not a method of assessment. Medication administration would come after clonus has been identified, not during the diagnostic step.

C. Perform a Romberg test: The Romberg test assesses balance and proprioception, often used in neurological exams for cerebellar or sensory dysfunction. It does not evaluate for clonus, which specifically relates to abnormal reflex activity.

D. Test the gait for symmetry: Gait assessment provides information about coordination, strength, and balance. While it may reveal neurologic impairment, it does not directly test for clonus or identify the rhythmic contractions associated with it.

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Correct Answer is A

Explanation

A. A client who has chronic back pain and a history of physical maltreatment: Therapeutic touch involves close physical proximity and intentional hand movements, which may trigger psychological distress or trauma responses in individuals with a history of maltreatment.

B. A client who has chronic joint discomfort and a history of mild dementia: Clients with mild dementia may still tolerate therapeutic touch well, as it can provide comfort and reduce agitation. With careful explanation and reassurance, this intervention can be beneficial.

C. A client who has chronic knee pain and a history of grand mal seizures: Therapeutic touch does not induce seizures, as it is a noninvasive energy-based practice. It does not increase seizure risk in clients with a seizure history.

D. A client who has chronic hip pain and a history of uterine cancer: Having a history of cancer is not a contraindication to therapeutic touch. This approach does not involve deep tissue manipulation and can be safely applied to provide comfort and pain relief.

A. A client who needs their daily weight taken with a bed scale B. A client who has a leg ulcer and needs their dressing changed C. A client who has an indwelling urinary catheter bag that needs to be emptied D. A client who has dysphagia and has a scheduled feeding

Correct Answer is D

Explanation

A. A client who needs their daily weight taken with a bed scale: Daily weight is important for monitoring fluid status, but it is not immediately life-threatening if delayed. This task can be completed after more urgent client needs are addressed.

B. A client who has a leg ulcer and needs their dressing changed: Dressing changes are important for preventing infection and promoting healing, but this intervention is not urgent compared to risks involving airway or nutrition.

C. A client who has an indwelling urinary catheter bag that needs to be emptied: Emptying a catheter bag helps with comfort and infection control but does not represent a priority safety concern. It can safely wait until more urgent tasks are completed.

D. A client who has dysphagia and has a scheduled feeding: Dysphagia places the client at high risk for aspiration during feeding, which can compromise the airway and lead to respiratory complications. This client requires the nurse’s immediate attention to ensure safe feeding.

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A nurse is caring for a client who has suspected clonus. Which of the following actions should the nurse take to assess for this condition?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

Explanation

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