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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
A. Amount of time washing hands: The client increased handwashing time to 15 seconds, which meets the CDC’s recommended minimum for effective hand hygiene when preparing food.
B. Use of cutting board: The client now uses separate cutting boards for raw meats and raw vegetables, which helps prevent cross-contamination and foodborne illness.
C. Defrosting of frozen foods: Defrosting foods in the refrigerator is a safe method that prevents bacterial growth, unlike leaving food on the countertop.
D. Leftover storage time in refrigerator: Storing leftovers in the refrigerator for a maximum of 2 days (or 7 days initially) demonstrates proper food handling to prevent spoilage and bacterial growth.This aligns with recommended guidelines.
E. Refrigerator temperature: Although the temperature has improved (now 5.6°C instead of 6.7°C), the ideal refrigerator temperature should be 4°C (40°F) or lower for optimal food safety.
F. Time leftovers sit unrefrigerated on countertop: Leaving leftovers at room temperature for 2 hours still meets the maximum allowable limit, but best practice is to refrigerate within 1 hour if the room temperature is high (above 90°F/32°C), which might not reflect consistent safe food handling in all conditions.
Correct Answer is A
Explanation
A. "I will be told about alternative procedures before I'm asked to sign the consent form." Understanding alternative options is a key component of informed consent. Clients must be informed about the risks, benefits, and alternatives to the proposed procedure so they can make a voluntary, educated decision.
B. "My nurse is responsible for obtaining informed consent." While nurses often witness the client’s signature and may provide teaching, the responsibility for obtaining informed consent legally lies with the provider performing the procedure, who must explain the details and answer questions.
C. "Once I sign the consent form, I cannot change my mind about having the procedure." Clients retain the right to withdraw consent at any time before the procedure begins. Signing the form does not waive this right, and they can refuse or delay the procedure if they choose.
D. "The consent form will include the estimated time for my recovery from the procedure." Recovery time is usually discussed during preoperative teaching but is not a required element of the consent form itself. The form primarily covers procedure details, risks, and alternatives.
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