A nurse in a provider's office is collecting data from a client. Which of the following actions should the nurse take to check the client's balance? (Select all that apply.)

Have the client perform heel-to-toe walking.

Perform Weber's test.

Check for a positive Babinski reflex.

Perform the Romberg test.

Have the client lie in bed and use his heel to draw a line on the opposite shin.

Answer and Explanation

Correct Answer : A,D,E

A. Have the client perform heel-to-toe walking: Heel-to-toe walking (tandem gait) assesses balance and coordination by challenging the client’s ability to maintain stability during a narrow base of support. Difficulty with this test can indicate problems with cerebellar function or proprioception, which are essential for balance.

B. Perform Weber’s test: Weber’s test evaluates hearing by assessing bone conduction and is not related to balance assessment. It helps differentiate between conductive and sensorineural hearing loss but does not provide information about vestibular function.

C. Check for a positive Babinski reflex: Babinski reflex testing assesses neurological function of the corticospinal tract but does not evaluate balance. A positive Babinski indicates upper motor neuron damage but is unrelated to equilibrium or postural control.

D. Perform the Romberg test: The Romberg test evaluates proprioception and balance by assessing the client’s ability to maintain standing posture with eyes closed. A positive Romberg sign suggests impaired proprioception or vestibular dysfunction affecting balance.

E. Have the client lie in bed and use his heel to draw a line on the opposite shin: This test evaluates coordination and proprioception, important components of balance, by assessing precise lower limb control. Difficulty performing this task may indicate issues with neuromuscular control or proprioception.

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Correct Answer is C

Explanation

A. "Why do you think you are dying?" This question can sound confrontational and may cause the client to feel defensive. It does not acknowledge the client’s feelings or encourage further communication about their concerns.

B. "I think you should have some quiet time to get some rest." While rest is important, this response dismisses the client’s emotional expression and does not address their fear or need for support regarding dying.

C. "You are concerned that you are dying?" This statement reflects the client’s feelings and encourages them to share more about their fears and concerns. It validates their emotions and opens a supportive dialogue.

D. "It is normal to feel this way with your type of cancer." Although normalizing feelings can be helpful, this response might minimize the client’s personal experience and does not directly explore their expressed worry about dying.

A. "Don't worry. Everything will work out for you." B. "We should talk about your decision later." C. "How will you discuss this decision with your loved ones?" D. "Your quality of life will be compromised if you make this decision."

Correct Answer is C

Explanation

A. "Don't worry. Everything will work out for you.": This response minimizes the client’s feelings and concerns, potentially invalidating their decision. It also avoids addressing the seriousness of the situation and does not encourage open communication or support.

B. "We should talk about your decision later.": Deferring the conversation may make the client feel ignored or unsupported. It is important to acknowledge and explore the client’s feelings and reasoning about discontinuing treatment promptly to provide appropriate care.

C. "How will you discuss this decision with your loved ones?": This response respects the client’s autonomy and opens a supportive dialogue. It encourages the client to consider communication with their support system and reflects a willingness to assist in the emotional and practical aspects of their decision.

D. "Your quality of life will be compromised if you make this decision.": This statement is judgmental and may induce guilt or fear. It does not respect the client’s right to make informed decisions about their own care and can hinder therapeutic communication.

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A nurse in a provider's office is collecting data from a client. Which of the following actions should the nurse take to check the client's balance? (Select all that apply.)

Nursing Test Bank

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