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

Choice A reason: A skilled nursing facility is not the best option for this client because it provides long-term care for clients who need 24-hour nursing supervision and assistance with activities of daily living, but not intensive rehabilitation.

Choice B reason: Home care services are not the best option for this client because they provide intermittent care for clients who are able to manage most of their needs at home, but not comprehensive rehabilitation.

Choice C reason: A rehabilitation facility is the best option for this client because it provides short-term care for clients who need intensive physical, occupational, and/or speech therapy to restore or improve their function and independencE.

Choice D reason: A sub-acute care facility is not the best option for this client because it provides intermediate care for clients who need less intensive medical and nursing care than in an acute hospital, but not specialized rehabilitation.

A. Collect fingerstick glucose levels B. Implement bleeding precautions C. Obtain daily weights D. Check urine for albumin

Correct Answer is A

Explanation

a) Collect fingerstick glucose levels.Correct

Collecting fingerstick glucose levels is the most important intervention for the PN to implement for a client who is receiving TPN. TPN is a method of feeding that bypasses the gastrointestinal tract and provides all the nutritional needs of the body through a vein. TPN contains a high concentration of glucose, which can cause hyperglycemia or ﬂuctuations in blood sugar levels. Therefore, it is essential to monitor the client's glucose levels frequently and adjust the infusion rate or insulin administration accordingly.

b) Implement bleeding precautions.

Implementing bleeding precautions is not the most important intervention for the PN to implement for a client who is receiving TPN. Bleeding precautions are measures to prevent or minimize bleeding in clients who have a high risk of hemorrhage due to conditions such as thrombocytopenia, coagulopathy, or anticoagulant therapy. TPN does not directly increase the risk of bleeding, although it may aﬀect the liver function and clotting factors in some cases². Therefore, bleeding precautions are not a priority for a client who is receiving TPN.

c) Obtain daily weights.

Obtaining daily weights is not the most important intervention for the PN to implement for a client who is receiving TPN. Obtaining daily weights is a way to monitor the client's ﬂuid balance, nutritional status, and response to therapy. TPN can cause ﬂuid overload, dehydration, or electrolyte imbalances in some cases²⁵. Therefore, obtaining daily weights is important, but not as important as monitoring glucose levels.

d) Check urine for albumin.

Checking urine for albumin is not the most important intervention for the PN to implement for a client who is receiving TPN. Checking urine for albumin is a way to detect proteinuria, which is an indicator of kidney damage or disease. TPN does not directly cause kidney problems, although it may aﬀect the renal function and urine output in some cases². Therefore, checking urine for albumin is not a priority for a client who is receiving TPN.

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The nurse notes that a client has ataxi

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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