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 D
Explanation
When handling an unused portion of an oral opioid analgesic after administration, the nurse should take the following action:
D) Return the unused portion to the locked narcotics storage location.
Returning the unused portion to the locked narcotics storage location is a crucial step to ensure proper control and documentation of controlled substances like opioids. It helps prevent diversion and ensures the security and accountability of these medications.
Options A, B, and C are not appropriate:
A) Sending the unused portion to the pharmacy is not typically the responsibility of the nurse, and it may not be a practical or safe option for controlled substances.
B) Having a second nurse verify disposal of the unused portion is not a standard practice for oral medication administration.
C) Keeping the unused portion in the client's medication drawer is not an appropriate method of handling unused controlled substances, as it lacks the necessary security and accountability measures.
Correct Answer is C
Explanation
Choice A rationale:
A client who needs assistance when ambulating is an important consideration for care, but it does not necessarily require a priority referral. The nurse can assess the client's mobility and coordinate assistance within the rehabilitation unit as needed.
Choice B rationale:
A client who consistently has difficulty using utensils while eating is a concern for occupational therapy or speech therapy, but it is not an immediate priority. The client's difficulty with eating utensils can be addressed through therapeutic interventions within the rehabilitation setting.
Choice C rationale:
A client who has expressive aphasia requires a priority referral because this indicates potential communication difficulties that could hinder the client's ability to express needs, understand instructions, and participate in therapy. Expressive aphasia can impact the client's overall rehabilitation progress and safety.
Choice D rationale:
A client who consistently coughs after drinking liquids might require assessment and intervention, but it does not present an immediate priority. The nurse can address this concern within the rehabilitation unit and collaborate with the interdisciplinary team as needed.
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