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.”
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B. "Tighten your stomach muscles.” This is because when turning an immobile client in bed, it’s important to use proper body mechanics to prevent injury. Tightening the stomach muscles helps to stabilize the core, which supports the spine and can help prevent back strain.
Choice A rationale:
"Keep your feet close together” is wrong because having a wide base of support with the feet apart provides better balance and stability when turning a client in bed.
Choice C rationale:
"Straighten your knees” is wrong because you should keep your knees slightly bent to maintain balance and allow for a smooth transfer of weight as you turn the client.
Choice D rationale:
"Bend at your waist” is wrong because bending at the waist increases the risk of a back injury. It’s important to bend the knees and keep the back straight when leaning over to turn a client.
Correct Answer is ["B","C","D"]
Explanation
The correct answer is choice b. Wash hands after removing gloves, c. Use antimicrobial hand gel after refilling a client’s water pitcher, and d. Clean the stethoscope with an antimicrobial wipe after obtaining vital signs.
Choice A rationale:
Placing immunocompromised clients in the same room can increase the risk of cross-infection among them. It is better to isolate them or place them in rooms with clients who have similar infection risks.
Choice B rationale:
Washing hands after removing gloves is crucial to prevent the spread of pathogens that might have contaminated the gloves during patient care.
Choice C rationale:
Using antimicrobial hand gel after refilling a client’s water pitcher helps to maintain hand hygiene and prevent the transmission of infections.
Choice D rationale:
Cleaning the stethoscope with an antimicrobial wipe after obtaining vital signs is essential to prevent the transfer of pathogens between patients.
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