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 B
Explanation
Choice A reason: Collaborating with physical therapist to develop programs for injured employees to return to work is not a secondary prevention strategy, but rather a tertiary prevention strategy, which involves restoring and rehabilitating the health and function of individuals who have experienced illness or injury.
Choice B reason: Helping plant workers identify signs of carpal tunnel syndrome is a secondary prevention strategy, which involves detecting and treating health problems early before they become more serious or complicateD.
Choice C reason: Organizing an influenza immunization campaign is not a secondary prevention strategy, but rather a primary prevention strategy, which involves preventing or reducing the occurrence or severity of health problems before they happen.
Choice D reason: Teaching plant workers about proper lifting techniques is not a secondary prevention strategy, but rather a primary prevention strategy, which involves preventing or reducing the occurrence or severity of health problems before they happen.
Correct Answer is D
Explanation
When providing instructions to a client with a below-the-knee cast for a compound fracture of the left ankle, it is important to prioritize their safety and proper care of the cast. The instruction to never scratch under the cast is crucial for preventing complications and maintaining the integrity of the cast.
Let's evaluate the other options:
a) Apply a cold pack to any "hot spots" on the cast.
Applying a cold pack to any "hot spots" on the cast may help alleviate discomfort or itching, but it is not the highest priority instruction. Preventing scratching under the cast is more important to avoid skin damage or infection.
b) Keep the left leg in a dependent position.
Keeping the left leg in a dependent position (hanging down) is not the appropriate instruction for a client with a below-the-knee cast. It is generally recommended to elevate the injured limb to reduce swelling and promote proper blood flow. Elevating the leg would involve keeping it raised above the level of the heart.
c) Expect some increase in pain.
While it is possible for the client to experience some increase in pain after the application of a cast, this instruction alone is not comprehensive or specific enough for proper discharge education. Providing information about pain management strategies or when to seek medical atention for excessive pain would be more appropriate.
In summary, when discharging a client with a compound fracture of the left ankle and a below-the-knee cast, the practical nurse (PN) should provide the instruction to never scratch under the cast. This helps prevent complications and maintain the integrity of the cast, promoting proper healing of the fracture.
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