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: Performing carotid massage is not an appropriate action for the nurse to take because it can worsen the client's condition by decreasing the blood flow to the brain, causing further ischemia or hemorrhagE. Carotid massage is a technique that involves applying pressure to the carotid artery to slow down the heart rate, which can be dangerous for clients who have a strokE.
Choice B reason: Calling for help is an appropriate action for the nurse to take because it can initiate the rapid response team and activate the stroke protocol, which can improve the client's outcome and survival. The nurse should also assess the client's vital signs, neurological status, and time of symptom onset, and report them to the health care provider.
Choice C reason: Providing the client with water to test the gag reflex is not an appropriate action for the nurse to take because it can increase the risk of aspiration and pneumonia, which can complicate the client's recovery and prognosis. The nurse should avoid giving anything by mouth to the client until their swallowing ability is evaluated by a speech therapist or a swallow study.
Choice D reason: Administering thrombolytics is not an appropriate action for the nurse to take because it requires a physician's order and confirmation of the type and cause of stroke by a computed tomography (CT) scan or magnetic resonance imaging (MRI) scan. Thrombolytics are drugs that dissolve blood clots and restore blood flow, which can be beneficial for clients who have ischemic stroke, but harmful for clients who have hemorrhagic strokE.
Correct Answer is A
Explanation
Seizure precauons are measures taken to protect a client who is at risk of having a seizure, which is a sudden and abnormal electrical acvity in the brain that can cause changes in behavior, movement, sensaon, or consciousness. Seizure precauons include providing a safe environment, monitoring the client's vital signs and neurological status, administering anconvulsant medicaons, and documenng the onset, duraon, and characteriscs of any seizure acvity³.
One of the potenal complicaons of a seizure is aspiraon, which is the inhalaon of foreign material into the lungs, such as saliva, vomit, or food. Aspiraon can cause choking, pneumonia, or respiratory distress. To prevent or treat aspiraon, the praccal nurse (PN) should ensure the ready availability of equipment to perform suconing of the trachea, which is the tube that connects the mouth and nose to the lungs. Suconing of the trachea involves inserng a catheter through the nose or mouth into the trachea and applying negave pressure to remove any secreons or debris from the airway.
Therefore, opon A is the correct answer, while opons B, C, and D are incorrect.
Opon B is incorrect because inserng a urinary catheter is not related to seizure precauons or aspiraon prevenon.
Opon C is incorrect because applying so restraints may not be necessary or appropriate for a client who requires seizure precauons, as they may interfere with the natural movements of the seizure or cause injury to the client.
Opon D is incorrect because inserng a nasogastric tube is not related to seizure precauons or aspiraon prevenon.
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