The nurse notes that a client has ataxia. Which test does the nurse use to gain more information about this client's gait?
Plantar flexion
Romberg
Achilles reflex
Patellar reflex
The Correct Answer is B
Choice A reason: Plantar flexion is the movement of the foot that points the toes downward. It is not a test for gait, but rather a test for muscle strength and nerve function in the lower leg.
Choice B reason: Romberg is a test for balance and coordination that 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. If the client sways or falls when their eyes are closed, it indicates a problem with their proprioception, which is the sense of position and movement of the body. Ataxia is a condition that affects proprioception and causes impaired gait, so Romberg is an appropriate test for it.
Choice C reason: Achilles reflex is the contraction of the calf muscle when the Achilles tendon is tapped. It is not a test for gait, but rather a test for spinal cord function and nerve damage in the lower leg.
Choice D reason: Patellar reflex is the extension of the lower leg when the patellar tendon is tapped. It is not a test for gait, but rather a test for spinal cord function and nerve damage in the upper leg.

Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: The AP's ability to complete the task without assistance is not one of the five rights of delegation. The nurse is responsible for providing adequate supervision and guidance to the AP, and ensuring that the task is done correctly and safely.
Choice B reason: The AP's ability to prioritize is not one of the five rights of delegation. The nurse is responsible for assigning tasks based on their urgency and importance and communicating clear expectations and deadlines to the AP.
Choice C reason: The AP's rapport with clients is not one of the five rights of delegation. The nurse is responsible for maintaining a therapeutic relationship with clients and respecting their preferences and needs.
Choice D reason: The AP has the knowledge and skill to perform the task is one of the five rights of delegation. The nurse is responsible for assessing the AP's competence and readiness to perform the task, and providing appropriate training and feedback if needed.

Correct Answer is D
Explanation
Choice A reason: Decreasing bright lights is an appropriate action for a nurse to take when caring for a client who has signs of meningitis, as it helps to reduce the photophobia (sensitivity to light) and headache that are common symptoms of the condition. However, this action is not the first priority, as it does not prevent the transmission of the infection or treat the underlying cause.
Choice B reason: Initiating IV access is an appropriate action for a nurse to take when caring for a client who has signs of meningitis, as it facilitates the administration of fluids, medications, and blood products that may be needed to manage the condition. However, this action is not the first priority, as it does not prevent the transmission of the infection or treat the underlying cause.
Choice C reason: Administering antibiotics is an appropriate action for a nurse to take when caring for a client who has signs of meningitis, as it helps to treat the bacterial infection that is the most common cause of the condition. However, this action is not the first priority, as it requires a prescription from the health care provider and confirmation of the diagnosis by laboratory tests such as blood culture or cerebrospinal fluid analysis.
Choice D reason: Implementing droplet precautions is the first priority action for a nurse to take when caring for a client who has signs of meningitis, as it helps to prevent the spread of the infection to other clients and staff members. Droplet precautions are a type of isolation precautions that are used for infections that are transmitted by respiratory droplets, such as meningitis, influenza, and pertussis. Droplet precautions involve wearing a surgical mask when entering the client's room, placing the client in a private room or cohorting with other clients who have the same infection, and limiting visitors and staff contact with the client.


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