A client reports dizziness on her yearly physical exam.
Which of the following tests would be the most appropriate to assess the client's equilibrium?
Romberg test.
Weber test.
Rinne test.
Cover test.
The Correct Answer is A
Choice A rationale
The Romberg test evaluates equilibrium by having the client stand with feet together and eyes closed, observing for swaying or imbalance. It assesses the function of the vestibular system, proprioception, and cerebellar function, making it the most appropriate test for assessing dizziness and equilibrium.
Choice B rationale
The Weber test involves placing a tuning fork on the forehead to evaluate sound lateralization. It assesses hearing loss but not equilibrium, making it less suitable for dizziness assessment.
Choice C rationale
The Rinne test compares air and bone conduction of sound using a tuning fork. While useful for diagnosing conductive hearing loss, it does not assess equilibrium, making it inappropriate for evaluating dizziness.
Choice D rationale
The cover test evaluates eye alignment and muscle function by having the client cover one eye and observe the uncovered eye for movement. It assesses ocular motility but not equilibrium, making it unsuitable for dizziness assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The general survey is an overall assessment of a client's physical appearance, behavior, mobility, and neurological status. It provides a comprehensive overview of the client's health and well-being, making it the focus of the nurse's observations in this scenario.
Choice B rationale
Medical history includes past and current health conditions, surgeries, medications, and family health history. While important, it is not the focus of the nurse's immediate observations in this scenario.
Choice C rationale
Biographical data involves personal information such as age, gender, occupation, and marital status. While relevant to the client's health, it is not the primary focus of the nurse's observations in this scenario.
Choice D rationale
Social history includes information about the client's lifestyle, habits, and social environment. While valuable for understanding the client's overall health context, it is not the focus of the nurse's immediate observations in this scenario. .
Correct Answer is A
Explanation
Choice A rationale
Rhonchi are low-pitched, continuous breath sounds that are often indicative of secretions in the large airways. These sounds may change or clear with coughing, so the nurse should have the patient cough and then auscultate again to reassess the presence of rhonchi.
Choice B rationale
Wheezes are high-pitched, musical sounds heard primarily during expiration. They are caused by narrowed airways, typically due to asthma or other obstructive lung conditions. Wheezes do not usually clear with coughing and require specific treatments to address airway constriction.
Choice C rationale
Crackles are discontinuous, popping sounds heard during inspiration and are associated with fluid in the alveoli, such as in conditions like pneumonia or heart failure. Crackles are not typically cleared by coughing and may persist despite the patient's efforts to clear their airways.
Choice D rationale
Stridor is a high-pitched, harsh sound heard during inspiration, often indicating upper airway obstruction. Stridor is a medical emergency and requires immediate intervention to secure the airway. It does not clear with coughing and signifies a critical respiratory issue. .
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