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 C

Explanation

When a client reports experiencing numbness and ngling in the extremies, it is crucial for the praccal nurse (PN) to prioritise reporting the client's electrolyte levels to the healthcare provider. Electrolytes are essential minerals that help maintain the balance of fluids in the body and enable proper nerve and muscle function. Imbalances in electrolyte levels can lead to neurological symptoms, including numbness and ngling.

Opons a, b, and d are not the correct priories to report in this situation:

a) Hematocrit: Hematocrit measures the proportion of red blood cells in the blood. While abnormalies in hematocrit can indicate certain conditions, such as anaemia, it is not directly associated with numbness and ngling in the extremes.

b) Albumin and protein levels: Albumin and protein levels are important for assessing nutritional status and liver function. While low levels of protein can contribute to various health issues, they are not the primary concern when a client experiences numbness and ngling in the extremities.

d) White blood cell count (WBC): WBC count is used to evaluate the immune system's response to infection or inflammation. While infections or inflammatory conditions can cause neurological symptoms, such as ngling, it is not the primary concern in this specific case of numbness and ngling.

Therefore, the most appropriate laboratory value to prioritise reporting in this scenario is the client's electrolyte levels, as imbalances can directly contribute to the reported symptoms and may require prompt intervention.

A. Limit fluid intake to prevent incontinence B. Provide regular perineal care to prevent skin breakdown C. Administer hypotonic IV fluids D. Teach Kegel exercises to strengthen the pelvic floor

Correct Answer is B

Explanation

Choice A reason: Limiting fluid intake to prevent incontinence is not the highest priority intervention for this client because it can cause dehydration, urinary tract infections, or kidney stones, which can worsen the client's condition and quality of lifE. The client should be encouraged to drink adequate fluids and empty their bladder regularly.

Choice B reason: Providing regular perineal care to prevent skin breakdown is the highest priority intervention for this client because it can prevent infection, irritation, and ulceration of the skin around the genital and anal areas, which can cause pain, discomfort, and complications. The client should be kept clean and dry, and use barrier creams or pads as needeD.

Choice C reason: Administering hypotonic IV fluids is not an intervention for this client because it can cause fluid overload, hyponatremia, or cerebral edema, which can endanger the client's health and safety. The client does not need IV fluids unless they are dehydrated or have other indications.

Choice D reason: Teaching Kegel exercises to strengthen the pelvic floor is not an intervention for this client because it can be ineffective or harmful for clients with reflex incontinence, which is caused by loss of voluntary control over bladder contractions due to spinal cord injury. The client may benefit from other interventions such as bladder training, medication, or surgery.

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The nurse notes that a client has ataxi

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client reports experiencing numbness and ngling in the extremies. Which of the client's serum laboratory values should the praccal nurse (PN) priorize reporng to the healthcare provider?

Correct Answer is C

Explanation

A client is receiving rehabilitation for paralysis following a spinal cord injury and is diagnosed with reflex incontinencE. Which of the following isthe highest priority intervention the nurse should include in the plan of care?

Correct Answer is B

Explanation

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