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.

Answer and Explanation

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

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Correct Answer is B

Explanation

Choice A rationale
Analgesics can be used to manage pain associated with Bell’s palsy. Therefore, this statement does not indicate a need for further education.
Choice B rationale

This is the correct answer. Chewing on the affected side can actually exacerbate swallowing issues. Therefore, this statement indicates a need for further education.
Choice C rationale
Brushing teeth should not be affected by Bell’s palsy. Therefore, this statement does not indicate a need for further education.
Choice D rationale
Applying a protective eye shield before going to bed is a recommended practice for patients with Bell’s palsy. This helps to protect the eye from injury and keep it moist, as Bell’s palsy can cause difficulty in blinking or closing the eye.

A. This type of delirium is treatable and the patient’s cognition will return to its previous levels. B. This issue can be resolved by administering antidotes to the anesthetic used in surgery. C. Delirium involves a progressive decline in memory loss and overall cognitive function. D. This problem is self-limiting and there is nothing to worry about.

Correct Answer is A

Explanation

Choice A rationale
Postoperative delirium is a common condition that can occur in older patients after surgery, especially major procedures like hip arthroplasty. It is characterized by a sudden onset of confusion and altered consciousness. This type of delirium is indeed treatable and most patients’ cognition will return to its previous levels. The treatment often involves addressing the underlying causes, such as pain, medication effects, or metabolic imbalances, and providing supportive care. It’s important for the family to understand that this is a temporary condition and does not indicate a permanent change in their loved one’s mental status.
Choice B rationale
While anesthetics can contribute to postoperative delirium, the condition is usually multifactorial and not solely due to the anesthetic used in surgery. Therefore, administering antidotes to the anesthetic is not typically how postoperative delirium is managed. Instead, the focus is on treating the underlying causes and providing supportive care.
Choice C rationale

Delirium does involve a disturbance in cognition, including memory impairment, but it does not involve a progressive decline in memory loss and overall cognitive function. That description is more characteristic of dementia, a different condition. Delirium is typically a temporary condition that improves once the underlying cause is addressed.
Choice D rationale
While postoperative delirium is often self-limiting, meaning it resolves on its own over time, it is not accurate to say there is nothing to worry about. Postoperative delirium can be distressing for the patient and their family, and in some cases, it can be associated with longer hospital stays and increased morbidity. Therefore, it is a condition that should be taken seriously and managed appropriately.

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During the performance of a Romberg test, the nurse observes the client sway slightly. What action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In the context of outpatient care for a client diagnosed with Bell’s palsy, which of the following statements, if made by the client, would indicate the need for further education?

Correct Answer is B

Explanation

Correct Answer is A

Explanation

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