The nurse is performing the Romberg test on a client during a neurological assessment. Which of the following best describes the rationale for conducting the Romberg test?

To measure respiratory rate and depth.

To evaluate coordination and fine motor skills.

To test for proprioception and vestibular function.

To assess cranial nerve function related to facial expression.

Answer and Explanation

The Correct Answer is C

Choice A reason:

The Romberg test is not used to measure respiratory rate and depth. Respiratory assessments involve observing breathing patterns, rate, and depth, which are unrelated to the Romberg test.

Choice B reason:

While the Romberg test can provide some information about coordination, its primary purpose is not to evaluate fine motor skills. Fine motor skills are typically assessed through tasks that involve precise hand and finger movements.

Choice C reason:

The Romberg test is used to test for proprioception and vestibular function. It assesses the client’s ability to maintain balance with their eyes closed, which helps identify issues with proprioception (the sense of body position) and vestibular function (the inner ear’s role in balance).

Choice D reason:

The Romberg test does not assess cranial nerve function related to facial expression. Cranial nerve assessments involve specific tests for each nerve, such as asking the client to smile or raise their eyebrows to evaluate facial nerve function.

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Correct Answer is C

Explanation

Choice A reason:

Assisting the client with active range of motion exercises is important for preventing complications such as contractures and maintaining mobility. However, it is not the priority intervention in the acute phase of a hemorrhagic stroke. The primary focus should be on stabilizing the client and monitoring their condition closely.

Choice B reason:

Maintaining strict bed rest to minimize cerebral blood flow is not appropriate for managing a hemorrhagic stroke. While bed rest may be necessary to prevent further injury, the priority is to monitor the client’s neurological status and vital signs to detect any changes that may indicate worsening of the condition.

Choice C reason:

Monitoring vital signs and neurological status frequently is the priority intervention for a client who has experienced a hemorrhagic stroke. Close monitoring allows the nurse to detect any changes in the client’s condition promptly and take appropriate action. This is crucial for preventing complications and ensuring timely intervention if the client’s condition deteriorates.

Choice D reason:

Administering anticoagulant medications is contraindicated in hemorrhagic stroke because they can exacerbate bleeding. Anticoagulants are used in ischemic stroke to prevent clot formation, but in hemorrhagic stroke, the focus is on controlling bleeding and stabilizing the client.

A. The client’s level of family support B. The client’s financial resources C. The client’s access to transportation D. The client’s ability to prepare meals

Correct Answer is D

Explanation

Choice A reason:

The client’s level of family support is important, but it is not the most critical factor in determining eligibility for Meals-on-Wheels. Family support can supplement the client’s needs, but the primary focus should be on the client’s ability to prepare meals independently.

Choice B reason:

The client’s financial resources are a consideration, but many Meals-on-Wheels programs offer services on a sliding scale or free of charge based on need. Financial resources alone do not determine eligibility; the ability to prepare meals is a more direct indicator of need.

Choice C reason:

The client’s access to transportation is relevant, especially if they need to travel to obtain food. However, Meals-on-Wheels is designed to serve homebound clients who cannot easily leave their homes, making transportation less of a concern compared to the ability to prepare meals.

Choice D reason:

The client’s ability to prepare meals is the most important factor in determining eligibility for Meals-on-Wheels. This program is specifically designed to assist individuals who are unable to prepare nutritious meals for themselves due to physical or cognitive limitations. Ensuring that clients receive adequate nutrition is the primary goal of the program.

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The nurse is performing the Romberg test on a client during a neurological assessment. Which of the following best describes the rationale for conducting the Romberg test?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has experienced a hemorrhagic stroke. Which intervention should the nurse prioritize when providing care to the client?

Correct Answer is C

Explanation

A nurse is determining if a homebound client is eligible for Meals-on-Wheels. Which of the following is the most important factor for the nurse to consider?

Correct Answer is D

Explanation

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