A nurse is caring for a client who has suspected clonus. Which of the following actions should the nurse take to assess for this condition?
Use a reflex hammer.
Administer magnesium sulfate.
Perform a Romberg test.
Test the gait for symmetry.
The Correct Answer is A
A. Use a reflex hammer: Clonus is assessed by using a reflex hammer to test deep tendon reflexes, typically at the ankle joint. Sustained rhythmic contractions following dorsiflexion of the foot confirm the presence of clonus, which often indicates upper motor neuron dysfunction.
B. Administer magnesium sulfate: Magnesium sulfate is a treatment used in conditions such as preeclampsia with severe features but is not a method of assessment. Medication administration would come after clonus has been identified, not during the diagnostic step.
C. Perform a Romberg test: The Romberg test assesses balance and proprioception, often used in neurological exams for cerebellar or sensory dysfunction. It does not evaluate for clonus, which specifically relates to abnormal reflex activity.
D. Test the gait for symmetry: Gait assessment provides information about coordination, strength, and balance. While it may reveal neurologic impairment, it does not directly test for clonus or identify the rhythmic contractions associated with it.
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Related Questions
Correct Answer is C
Explanation
A. Change the secondary IV infusion set twice weekly: Secondary IV sets, such as piggyback infusions, should generally be changed every 24 hours to reduce the risk of contamination and infection. Changing them twice weekly would not maintain proper asepsis.
B. Change a continuously infusing IV bag after 48 hr: Continuous IV bags should be replaced at least every 24 hours to prevent bacterial growth. Waiting 48 hours increases the risk of microbial contamination and bloodstream infections.
C. Change the primary IV infusion set every 96 hr: Changing the primary IV infusion set every 96 hours (4 days) aligns with standard infection-control guidelines. This interval helps maintain asepsis while minimizing the risk of IV-related infections.
D. Change the extension tubing once per week: Extension tubing connected to the IV line should be changed more frequently, typically every 72 to 96 hours, to prevent contamination. Once per week is too infrequent and increases infection risk.
Correct Answer is D
Explanation
A. 15°: This angle is used for intradermal injections, such as a tuberculin skin test, where the medication is deposited just under the epidermis. It would not allow the needle to reach the muscle layer, making it inappropriate for intramuscular administration.
B. 60°: An angle of 60° is not a standard technique for any specific injection type. At this angle, the medication would likely end up in the subcutaneous tissue instead of the muscle, leading to improper absorption and reduced effectiveness.
C. 45°: This angle is appropriate for subcutaneous injections, such as insulin, when a shorter needle is used or in thin clients. It does not penetrate deeply enough to reach the muscle tissue for intramuscular medication administration.
D. 90°: A 90° angle ensures the needle penetrates through the subcutaneous tissue and into the muscle, which is necessary for intramuscular injections. This angle allows the medication to be deposited directly into the muscle for proper absorption and therapeutic effect.
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