A nurse is performing a focused assessment of a client's sensory functions. Which of the following tests should the nurse perform?

Walking gait test.

Plantar reflex test.

Finger-to-nose test.

Romberg test.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

The walking gait test is used to assess a client's walking pattern and balance, particularly for identifying abnormalities in gait. However, it doesn't specifically evaluate sensory functions, making it an inappropriate choice for this scenario.

Choice B rationale:

The plantar reflex test, also known as the Babinski reflex test, assesses the neurological integrity of the corticospinal tract. It involves stimulating the sole of the foot to elicit specific reflex movements. While this test is important in assessing neurological function, it doesn't directly evaluate sensory functions as requested in the question.

Choice C rationale:

The finger-to-nose test is a part of the neurological examination used to assess a client's coordination and proprioception. In this test, the client is asked to touch their nose with their index finger while alternating between eyes closed and eyes open. This evaluates their ability to sense the position of their limbs in space (proprioception) and their coordination. It directly addresses the focus of the question, making it the correct choice.

Choice D rationale:

The Romberg test evaluates a client's balance and proprioception. It involves having the client stand with their feet together and their eyes closed to assess their ability to maintain balance without visual input. While this test is relevant to sensory functions, it primarily assesses proprioception and balance rather than coordination, which the question is specifically targeting.

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Correct Answer is A

Explanation

To calculate how many milliliters (mL) of diazepam oral solution should be administered, you can use the following formula:

Dose (mL) = Desired dose (mg) / Concentration (mg/mL)

In this case, the desired dose is 2 mg, and the concentration of the diazepam oral solution is 5 mg/1 mL.

Dose (mL) = 2 mg / 5 mg/mL = 0.4 mL

So, the nurse should administer 0.4 mL of diazepam oral solution with each dose. The correct answer is:

A) 0.4 mL.

A. Perform oral care once each day. B. Brush the client's teeth with a firm-bristle toothbrush. C. Swab the client's mouth with chlorhexidine solution. D. Raise the head of the bed 15° for oral care.

Correct Answer is C

Explanation

Choice A rationale:

Performing oral care once each day is not sufficient to reduce the risk of ventilator-associated pneumonia (VAP). Ventilated patients are at an increased risk of developing VAP due to the presence of an endotracheal tube that bypasses the body's natural defenses. Bacteria can accumulate in the mouth and respiratory tract, leading to pneumonia. Therefore, performing oral care only once a day is inadequate for maintaining oral hygiene and preventing VAP.

Choice B rationale:

Brushing the client's teeth with a firm-bristle toothbrush can cause trauma to the oral tissues, potentially leading to bleeding and irritation. In critically ill patients with an endotracheal tube, using a firm-bristle toothbrush can exacerbate the risk of infection and VAP. It is essential to use gentle and non-traumatic methods for oral care to maintain the integrity of the oral mucosa.

Choice C rationale:

Swabbing the client's mouth with chlorhexidine solution is the correct choice. Chlorhexidine is an antiseptic solution that effectively reduces the growth of bacteria in the oral cavity. Regular use of chlorhexidine mouthwash has been shown to decrease the risk of VAP in mechanically ventilated patients. By reducing the bacterial load in the mouth, the risk of aspiration and subsequent pneumonia is lowered, making it a crucial intervention for preventing VAP.

Choice D rationale:

Raising the head of the bed by 15° for oral care is an important measure to prevent aspiration during oral care. However, it alone is not sufficient to reduce the risk of VAP. While proper head positioning helps prevent the entry of oral secretions into the lower respiratory tract, it must be combined with effective oral hygiene practices, such as using chlorhexidine solution, to comprehensively reduce the risk of VAP.

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A nurse is performing a focused assessment of a client's sensory functions. Which of the following tests should the nurse perform?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer diazepam 2 mg twice daily via NG tube. Available is diazepam oral solution 5 mg/1 mL. How many mL should the nurse administer with each dose?

Correct Answer is A

Explanation

A nurse is planning care for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following interventions should the nurse include to reduce the client's risk for ventilator-associated pneumonia?

Correct Answer is C

Explanation

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