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
After a lumbar puncture, it is important for the patient to lie flat for approximately 6 hours. This position helps to prevent headaches that can occur after the procedure, which are caused by leakage of cerebrospinal fluid at the needle puncture site. Lying flat allows the puncture site to seal and prevents the leakage of cerebrospinal fluid.
Choice B rationale
Having the patient lie in a semi-Fowler’s position with the head of the bed at 35 degrees is not typically recommended immediately after a lumbar puncture. This position could potentially increase the risk of a post-lumbar puncture headache.
Choice C rationale
Early ambulation is not recommended after a lumbar puncture. Moving around too soon after the procedure can increase the risk of a headache and may also increase the risk of complications at the puncture site.
Choice D rationale
Having the patient lie flat for 1 hour, then sit up for 1 hour before ambulating is not a typical recommendation after a lumbar puncture. The standard recommendation is to have the patient lie flat for approximately 6 hours to reduce the risk of complications.
Correct Answer is A
Explanation
Choice A rationale
Status epilepticus is a medical emergency characterized by continuous or rapid-fire seizures. Intravenous diazepam is one of the first-line treatments for this condition. It works by enhancing the effect of gamma-aminobutyric acid (GABA), a neurotransmitter that inhibits brain activity, thereby helping to stop the seizure.
Choice B rationale
Oral lorazepam is not typically used to halt a seizure immediately due to its slower onset of action compared to intravenous administration.
Choice C rationale
Oral phenytoin is not typically used to halt a seizure immediately. It is more commonly used for the long-term management of seizures.
Choice D rationale
Intravenous phenobarbital is a second-line treatment for status epilepticus, used when first- line treatments such as diazepam are ineffective.
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