The nurse notes that a client has ataxi

Plantar flexion

Romberg

Achilles reflex

Patellar reflex

Answer and Explanation

The Correct Answer is B

Choice A reason: Plantar flexion is not a test that the nurse uses to gain more information about this client's gait because it is a movement of the foot that points the toes downward, not a measure of balance or coordination.

Choice B reason: Romberg is a test that the nurse uses to gain more information about this client's gait because it is a measure of balance and proprioception, which are often impaired in ataxiA. The test involves asking the client to stand with their feet together and arms at their sides, first with their eyes open and then with their eyes closed, while observing for swaying or fallinG.

Choice C reason: Achilles reflex is not a test that the nurse uses to gain more information about this client's gait because it is a measure of the reflex response of the calf muscle when the Achilles tendon is tapped, not a measure of balance or coordination.

Choice D reason: Patellar reflex is not a test that the nurse uses to gain more information about this client's gait because it is a measure of the reflex response of the quadriceps muscle when the patellar tendon is tapped, not a measure of balance or coordination.

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Correct Answer is A

Explanation

Choice A reason: Planning medication doses to occur before meals is a good suggestion to improve this client's nutritional status because it can enhance the client's muscle strength and coordination for chewing and swallowing, which are often impaired by myasthenia gravis.

Choice B reason: Restricting drinking fluids before and during meals is not a good suggestion to improve this client's nutritional status because it can increase the risk of dehydration and constipation, which can worsen the client's condition and appetitE.

Choice C reason: Increasing the amount of fat and carbohydrates in meals is not a good suggestion to improve this client's nutritional status because it can lead to weight gain, hyperglycemia, and cardiovascular problems, which can complicate the management of myasthenia gravis.

Choice D reason: Eating three large meals per day is not a good suggestion to improve this client's nutritional status because it can cause fatigue, bloating, and aspiration, which can affect the client's ability and willingness to eat. The client should eat small, frequent meals that are easy to chew and swallow.

A. Monitoring vital signs and neurological status frequently. B. Maintaining strict bed rest to minimize cerebral blood flow. C. Administering anticoagulant medications as prescribeD. D. Assisting the client with active range of motion exercises.

Correct Answer is A

Explanation

Choice A reason: Monitoring vital signs and neurological status frequently is the priority intervention for the client because it can detect changes in the client's condition, such as increased intracranial pressure, bleeding, or infection, that require immediate action.

Choice B reason: Maintaining strict bed rest to minimize cerebral blood flow is not the priority intervention for the client because it can increase the risk of complications such as deep vein thrombosis, pulmonary embolism, or pneumoniA. The client should be positioned with the head of the bed elevated at 30 degrees to reduce intracranial pressure and facilitate drainagE.

Choice C reason: Administering anticoagulant medications as prescribed is not the priority intervention for the client because it can worsen the bleeding and increase the risk of hemorrhagic transformation. Anticoagulants are contraindicated for clients who have hemorrhagic stroke, which is caused by rupture of a blood vessel in the brain.

Choice D reason: Assisting the client with active range of motion exercises is not the priority intervention for the client because it can cause fatigue, pain, or injury to the affected limbs. The client should be assisted with passive range of motion exercises to prevent contractures and maintain joint mobility.

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The nurse notes that a client has ataxi

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with myasthenia gravis has lost 6 kg of weight over the last 2 months. What should the nurse suggest to improve this client's nutritional status?

Correct Answer is A

Explanation

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 A

Explanation

A nurse is delegating tasks to the assistive personnel (AP). The nurse should direct the AP to complete which of the following tasks first?

A nurse is caring for a client with a myocardial infarction. The client questions the need for cardiac rehabilitation since "my heart is already damageD." Which of the following is the appropriate nursing response?

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A nurse has identified a community at risk for floodinG. The nurse understands that educating the residents about evacuation routes and emergency shelters is an example of what level of the National Response Framework?

An occupational health nurse in the clinic of an industrial plant is developing a guidebook for clinic workers. Which of the following actions shouldthe nurse include as a secondary prevention strategy?

An older female client who resides in a long-term care facility has a male friend who often visits her in the evenings. The practical nurse (PN) enters the client's room to administer medications and finds the couple in bed together. What action should the PN take?

A nurse advises a client with osteoporosis to have three servings of milk or dairy products daily. Which of the following levels of prevention is being used by the nurse?

The mother of a school-aged boy tells the praccal nurse (PN) that he fell out of a tree and hurt his arm and shoulder. Which assessment should the praccal nurse (PN) note as the most significant indicator of possible child abuse?