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 A

Explanation

A. "He is allergic to sulfa." Communicating a client’s allergies during transfer is critical to ensure patient safety and prevent adverse reactions. This information directly impacts medication administration and care planning on the receiving unit, making it essential to include in the transfer report.

B. "His partner has been visiting." While family involvement can be helpful, details about visitors are generally less urgent and not typically necessary in a transfer report unless they directly affect the client’s care or safety.

C. "He appears anxious about the transfer." Emotional status is important but is secondary to clinical information. If anxiety significantly affects the client’s care or safety, it might be mentioned, but it is not a priority in a transfer report focused on immediate clinical needs.

D. "He is voiding adequately." Although voiding status is relevant to some clients’ care, it is less critical than allergy information unless the client has a specific condition affecting urinary function that requires close monitoring. The allergy detail remains a higher priority in transfer communication.

A. "I should stop receiving Papanicolaou tests once I reach menopause." B. "I might have headaches due to a decline in my estrogen levels." C. "The best time to perform a breast self-examination is on the first day of my period." D. "I can expect to have regular periods until I am in menopause."

Correct Answer is B

Explanation

A. "I should stop receiving Papanicolaou tests once I reach menopause”: Discontinuing Pap tests solely based on menopause is not recommended. Screening continues until at least age 65, depending on the individual's health history and prior screening results. Regular cervical cancer screening is important for early detection, even after menstruation stops.

B. "I might have headaches due to a decline in my estrogen levels”: Fluctuating and declining estrogen levels during perimenopause can trigger headaches or worsen existing ones. Hormonal changes affect blood vessels and neurotransmitters, contributing to the development of migraines or tension headaches in many women during this stage.

C. "The best time to perform a breast self-examination is on the first day of my period”: The ideal time is 7 to 10 days after the start of the menstrual period, when hormonal influence on breast tissue is minimal. Performing it on the first day of menstruation may result in increased tenderness and swelling, making it harder to detect abnormalities.

D. "I can expect to have regular periods until I am in menopause.": Perimenopause is typically marked by irregular menstrual cycles due to hormonal shifts. Periods may become lighter, heavier, more or less frequent before stopping altogether.

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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.)

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Correct Answer is B

Explanation

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