The nurse notes that a client has ataxi
Plantar flexion
Romberg
Achilles reflex
Patellar reflex
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Decreasing bright lights is not the first action that the nurse should perform because it does not address the priority problem of potential infection and inflammation of the meninges, which can cause serious complications such as brain damage or deatH. Decreasing bright lights can help reduce photophobia and headache, but it is not an urgent intervention.
Choice B reason: Initiating IV access is not the first action that the nurse should perform because it does not address the priority problem of potential infection and inflammation of the meninges, which can cause serious complications such as brain damage or deatH. Initiating IV access can facilitate fluid and medication administration, but it is not an immediate intervention.
Choice C reason: Administering antibiotics is not the first action that the nurse should perform because it requires a physician's order and confirmation of the diagnosis and causative organism by laboratory tests such as blood culture or cerebrospinal fluid (CSF) analysis. Administering antibiotics can treat bacterial meningitis, but it is not a priority intervention.
Choice D reason: Implementing droplet precautions is the first action that the nurse should perform because it addresses the priority problem of potential infection and inflammation of the meninges, which can cause serious complications such as brain damage or deatH. Implementing droplet precautions can prevent transmission of meningitis to other clients or staff, as meningitis can be spread by respiratory droplets from coughing, sneezing, or talkinG.
Correct Answer is B
Explanation
Choice A reason: Developing a survey on teen pregnancies is not an appropriate action by the nurse because it does not address the issue of influenza A outbreak in the school, which can affect students of any age or gender.
Choice B reason: Holding a focus group to discuss immunizations is an appropriate action by the nurse because it can educate and inform parents and students about the benefits and risks of influenza vaccination, as well as encourage them to get vaccinated before or during flu season.
Choice C reason: Running a mandatory flu clinic is not an appropriate action by the nurse because it can violate the rights and autonomy of parents and students who may have medical or personal reasons for refusing influenza vaccination, as well as create resentment and resistance among them.
Choice D reason: Closing the school for 6 weeks is not an appropriate action by the nurse because it can disrupt the education and socialization of students, as well as cause economic and logistic problems for parents and teachers. The recommended duration of school closure for influenza A outbreak is 5 to 7 days, which is the typical incubation period of the virus.
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