A nurse is providing information to a client immediately before his scheduled Romberg test.

Which of the following statements should the nurse make?

"You will be standing with your feet 1 foot apart."

"You will place and hold your hands on your hips."

"I will be standing across the room from you to evaluate your sense of balance."

"I will be checking you once with your eyes open and once with them closed."

Answer and Explanation

The Correct Answer is D

A is incorrect because the client should stand with their feet together, not 1 foot apart, for the Romberg test.

B is incorrect because the client should hold their arms at their sides, not on their hips, for the Romberg test.

C is incorrect because the nurse should stand close to the client, not across the room, to prevent injury in case of a fall.

D is correct because the Romberg test involves checking the client's balance with their eyes open and then with their eyes closed.

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Correct Answer is D

Explanation

- A. Diarrhea is not an adverse effect of amitriptyline, which is a tricyclic antidepressant (TCA). Diarrhea may be caused by other factors, such as infection, food intolerance, or stress. Therefore, this choice is incorrect.

- B. Frequent urination is not an adverse effect of amitriptyline either. Frequent urination may be a sign of diabetes, urinary tract infection, or other conditions that affect the kidneys or bladder. Therefore, this choice is also incorrect.

- C. Excessive salivation is not an adverse effect of amitriptyline as well. Excessive salivation may be due to increased production of saliva, difficulty swallowing, or mouth irritation. Therefore, this choice is incorrect too.

- D. Blurred vision is an adverse effect of amitriptyline and other TCAs. Amitriptyline can cause anticholinergic effects, such as dry mouth, constipation, urinary retention, and blurred vision. These effects are more pronounced in older adults and can impair their daily functioning and quality of life. Therefore, this choice is correct and the nurse should identify it as an adverse effect of the medication.

A. "I can keep a can of concentrated formula in the refrigerator for 3 days after I open it.” B. "I can dilute the ready-to-feed formula with water when my baby wants more than 4 ounces at a feeding.” C. "I should boil tap water for 2 minutes and cool it before I mix it with the powdered formula.” D. "I will be sure that all of my bottles contain BPA.”

Correct Answer is C

Explanation

Choice A rationale:

Keeping a can of concentrated formula in the refrigerator for 3 days after opening it is not safe. Once a can of formula is opened, it should be used within 24 hours and stored in the refrigerator. After 24 hours, any leftover formula should be discarded to prevent the risk of bacterial contamination.

Choice B rationale:

Diluting ready-to-feed formula with water is incorrect. Ready-to-feed formula is already prepared and does not need to be diluted further. Adding water to ready-to-feed formula can dilute its nutritional content and may not provide the necessary nutrients for the baby.

Choice C rationale:

Boiling tap water for 2 minutes and cooling it before mixing it with powdered formula is the correct method for safe formula preparation. Boiling the water kills harmful bacteria and ensures the formula is safe for the baby to consume. It is essential to cool the boiled water before mixing it with powdered formula to reach an appropriate feeding temperature.

Choice D rationale:

Ensuring that all bottles contain BPA (bisphenol A) is not a relevant consideration for formula preparation. BPA is a chemical that was previously used in some plastics, including baby bottles, but has been banned in baby bottles and sippy cups in several countries due to its potential health risks. Most modern baby bottles are BPA-free, and this statement does not address the safe handling and preparation of formula for the baby.

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A nurse is providing information to a client immediately before his scheduled Romberg test. Which of the following statements should the nurse make?

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A nurse is providing information to a client immediately before his scheduled Romberg test.

Which of the following statements should the nurse make?