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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choiceC. “I’ll compare the sensations I feel when I tense my muscles to what I feel when I relax them.”
Choice A rationale:While breathing normally is important during relaxation techniques, progressive muscle relaxation specifically focuses on tensing and relaxing muscle groups to recognize the difference in sensations.
Choice B rationale:Imagining a peaceful setting is more related to guided imagery or visualization techniques, not progressive muscle relaxation.
Choice C rationale:This is correct because progressive muscle relaxation involves tensing and then relaxing muscle groups to help the individual recognize the difference between tension and relaxation.
Choice D rationale:Using a series of stretches is not a part of progressive muscle relaxation; it is more related to stretching exercises or yoga.
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale: Placing a sterile kit on the overbed table above waist level maintains the sterility of the field. This position ensures that the kit is not contaminated by lower surfaces or inadvertent touch, which is essential for preventing infection during dressing changes.
Choice B rationale: Opening the outermost flap of the sterile kit toward their body increases the risk of contaminating the sterile field. The first flap should be opened away from the body to maintain the sterility of the field and prevent contamination.
Choice C rationale: Turning their back to the sterile field when coughing is incorrect because it increases the risk of contamination. The nurse should step away from the sterile field and cough into their elbow or use a mask to maintain sterility.
Choice D rationale: Holding a package of sterile gauze 30.5 cm (12 in) above the sterile field when dropping the gauze onto the field is too high and increases the risk of contamination. The gauze should be held closer, approximately 6 inches above the field, to ensure accuracy and sterility.
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