A nurse is preparing a client for a Romberg test. Which of the following statements should the nurse make?

"Stand with your feet together and your arms at your sides.”

"After I place the tuning fork, tell me when you no longer hear the sound.”

"I'm going to stroke the lateral side of the bottom of your foot.”

"Touch each fingertip as quickly as possible with your thumb.”

Answer and Explanation

The Correct Answer is A

The correct answer is choice A: "Stand with your feet together and your arms at your sides."

Choice A rationale:

This statement is correct. The nurse should instruct the client to stand with their feet together and their arms at their sides for a Romberg test. This position helps to assess the client's ability to maintain balance with minimal sensory input, evaluating their proprioception and vestibular function.

Choice B rationale:

The instruction about the tuning fork is unrelated to the Romberg test. The tuning fork is commonly used to assess hearing and vibratory sensations, not balance.

Choice C rationale:

This statement is unrelated to the Romberg test. Mentioning the lateral side of the foot suggests a neurological examination related to assessing reflexes, such as the Babinski reflex.

Choice D rationale:

This instruction pertains to a different test known as the "finger-to-nose" test, which is used to assess coordination, not balance.

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Correct Answer is D

Explanation

The correct answer is choiced. "Describe your concerns about sleeping to me.".

Choice A rationale:

While offering frequent checks can provide some reassurance, it does not address the underlying fear the client is experiencing. It is more of a practical solution rather than a therapeutic one.

Choice B rationale:

Agreeing with the client’s fear without offering a solution or support can increase their anxiety. It is important to acknowledge their feelings but also to provide comfort and reassurance.

Choice C rationale:

Offering sleeping medication might help the client fall asleep, but it does not address the root cause of their fear. It is important to understand and address the client’s concerns directly.

Choice D rationale:

Asking the client to describe their concerns is a therapeutic approach that encourages them to express their fears.This allows the nurse to understand the client’s perspective and provide appropriate emotional support.

A. A client who has pneumonia. B. A client who has measles. C. A client who has pertussis. D. A client who has methicillin-resistant Staphylococcus aureus (MRSA).

Correct Answer is B

Explanation

The correct answer is choice B: A client who has measles.

Choice A rationale:

Airborne precautions are indicated for diseases that spread via small particles suspended in the air, such as droplets or dust particles that remain in the air for prolonged periods. Pneumonia is primarily spread through larger respiratory droplets and is not considered an airborne disease. Therefore, airborne precautions are not necessary for a client with pneumonia.

Choice B rationale:

Measles is a highly contagious airborne disease caused by the measles virus. It is transmitted through respiratory droplets and can remain in the air for an extended period. Initiating airborne precautions, such as wearing an N95 respirator mask and placing the client in a negative pressure isolation room, is crucial to prevent the spread of measles to healthcare workers and other patients.

Choice C rationale:

Pertussis (whooping cough) is primarily spread through respiratory droplets, similar to pneumonia. While it is a serious bacterial infection, it is not classified as an airborne disease. Thus, airborne precautions are not required for a client with pertussis.

Choice D rationale:

Methicillin-resistant Staphylococcus aureus (MRSA) is mainly spread through direct contact with contaminated surfaces or individuals. Airborne precautions are not necessary for MRSA, as it is not transmitted through the air. Standard precautions, including wearing gloves and gowns, are typically sufficient when caring for a client with MRSA.

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A nurse is preparing a client for a Romberg test. Which of the following statements should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the admission of an older adult client to an acute care facility. The client states that they are afraid to go to sleep, fearing they will not wake up. Which of the following is a therapeutic response the nurse should make?

Correct Answer is D

Explanation

A nurse is contributing to the plan of care for four clients. For which of the following clients should the nurse initiate airborne precautions?

Correct Answer is B

Explanation

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