During the performance of a Romberg test, the nurse observes the client sway slightly. What action should the nurse take?
Follow up by having the client perform the Rinne test
Reposition the client supine to ensure safety.
Document successful completion of the assessment.
Facilitate a referral to a neurologist.
The Correct Answer is C
Choice A rationale
The Rinne test is a hearing test used to evaluate the difference between sound transmission through air conduction versus bone conduction. It is not typically used following a Romberg test, which evaluates balance.
Choice B rationale
While ensuring the patient’s safety is always important, repositioning the client supine is not the typical response to slight swaying during a Romberg test.
Choice C rationale
Slight swaying during a Romberg test is considered normal. Therefore, documenting successful completion of the assessment would be the appropriate action.
Choice D rationale
A referral to a neurologist is not typically necessary for slight swaying during a Romberg test, as this is considered within normal limits.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Donepezil hydrochloride is a medication used to treat dementia related to Alzheimer’s disease. It works by improving mental function, such as memory and the ability to think and reason.
However, it is important to note that donepezil does not cure Alzheimer’s disease. The condition will worsen over time, even in people who take donepezil.
Choice B rationale
Donepezil does not limit the physical effects of Alzheimer’s disease and other dementias. While it can improve cognitive function, it does not directly impact the physical symptoms associated with these conditions.
Choice C rationale
Donepezil does not remove the patient’s insight that they have Alzheimer’s disease. It is a medication that helps to improve cognitive function, but it does not alter a person’s awareness or understanding of their condition.
Choice D rationale
Donepezil does not cure Alzheimer’s disease in any patients, let alone a small minority. It is a treatment that can help manage symptoms and improve cognitive function, but it does not stop the progression of the disease.
Correct Answer is C
Explanation
Choice A rationale
While participation in multiple-step activities can provide mental stimulation, it may be challenging for a patient with Alzheimer’s disease. These activities often require a level of cognitive functioning that may be impaired in Alzheimer’s patients. As a result, these activities could lead to frustration and agitation rather than fostering socialization.
Choice B rationale
Hobbies involving fine motor skills can be beneficial for maintaining dexterity and coordination. However, as Alzheimer’s disease progresses, these skills often decline. Therefore, while these hobbies may be enjoyable, they may not necessarily foster socialization.
Choice C rationale
Limiting visitors to one or two at a time can help to prevent overstimulation, which can be distressing for a person with Alzheimer’s disease. Smaller, more intimate gatherings can also foster more meaningful social interactions. Therefore, this approach can be beneficial for promoting socialization.
Choice D rationale
While social interaction is important for people with Alzheimer’s disease, frequent lengthy visits from friends may be overwhelming and lead to fatigue. It’s important to balance socialization with rest and relaxation. Therefore, promoting frequent lengthy visits may not be the best approach to foster socialization.
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