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 C
Explanation
Choice A reason: A negative-pressure isolation room is not appropriate for this client because it is used for clients who have airborne infections that can spread through small droplets that remain suspended in the air, such as tuberculosis, measles, or chickenpox. Scabies is a skin infection that is spread by direct contact with infested skin or clothinG.
Choice B reason: A positive-pressure isolation room is not appropriate for this client because it is used for clients who have compromised immune systems and need protection from environmental contaminants, such as bone marrow transplant recipients, burn victims, or organ transplant recipients. Scabies is not caused by environmental contaminants, but by parasitic mites that burrow under the skin.
Choice C reason: A private room is appropriate for this client because it prevents contact transmission of scabies to other clients or stafF. The client should also have dedicated equipment and linens, and wear gloves and gown when leaving the room. The room should be thoroughly cleaned and disinfected after the client's dischargE.
Choice D reason: A semi-private room with a client who has pediculosis capitis is not appropriate for this client because it increases the risk of cross-contamination between the two clients. Pediculosis capitis is a head lice infestation that can also be spread by direct contact with infested hair or personal items.
Correct Answer is A
Explanation
Choice A reason: "It is a tool that is used to determine your maximum level of self-sufficiency.” This nursing response is appropriate because it accurately describes the purpose of the FIM, which is a standardized instrument that measures the client's level of independence in performing 18 activities of daily living and mobility tasks.
Choice B reason: "It is a test that determines which activities you feel most comfortable performinG.” This nursing response is not appropriate because it does not describe the purpose of the FIM, which is not a test that measures the client's comfort level, but rather their functional ability.
Choice C reason: "It is a tool used by insurance companies to determine qualifications for medical reimbursement." This nursing response is not appropriate because it does not describe the purpose of the FIM, which is not a tool that determines the client's eligibility for insurance coverage, but rather their functional status and progress.
Choice D reason: "It is a tool that is used to assess what services you will need a home health aide to perform for you." This nursing response is not appropriate because it does not describe the purpose of the FIM, which is not a tool that evaluates the client's need for home care services, but rather their functional capacity and improvement.
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