A nurse is completing the Romberg's test on a patient. Which is the correct technique for conducting this?
Instruct the client to lie on his back and slowly slide his heel down the shin of the opposite leg, from the knee to the ankle.
Instruct the client to walk across the room on his heels and to return walking on his toes.
Have the client stand with feet together, arms at the sides. Begin with eyes open then with eyes closed. Try to maintain position for 20 seconds.
Ask the client to touch the thumb of one hand to each finger on that same hand and then repeat using the other hand.
The Correct Answer is C
Choice A reason: Heel-to-shin tests cerebellar coordination, not balance like Romberg’s. It assesses motor precision, not proprioception or vestibular function, which Romberg’s targets by checking sway with eyes closed, making this technique irrelevant to the intended assessment here.
Choice B reason: Walking on heels and toes evaluates motor strength and coordination, not stationary balance. Romberg’s tests proprioceptive stability, not gait, missing the core focus on vestibular and sensory integration critical to this neurological balance assessment fully.
Choice C reason: Romberg’s test assesses balance by having the client stand, feet together, eyes open then closed for 20 seconds. Sway with eyes closed indicates proprioceptive or vestibular issues, making this the precise, standard technique for this evaluation accurately.
Choice D reason: Finger-to-thumb tests fine motor skills and coordination, not balance. Romberg’s focuses on postural stability via sensory input, not hand dexterity, rendering this action unrelated to assessing the client’s equilibrium as intended in this context completely.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Tonsils touching the uvula indicate 4+ grading, where they obstruct over 75% of the oropharynx. This severe enlargement, with sore throat, fits the highest scale, reflecting significant inflammation or infection impacting airway and swallowing, accurately documented here.
Choice B reason: 1+ tonsils are slightly enlarged, less than 25% of the oropharynx, visible but not near the uvula. This underestimates the finding of tonsils contacting the uvula, misrepresenting the degree of obstruction and inflammation present in this case entirely.
Choice C reason: 2+ tonsils occupy 25-50% of the oropharynx, not touching the uvula. This moderate grade doesn’t match the observed contact, understating the severity of enlargement and potential airway compromise noted during the inspection clearly and significantly.
Choice D reason: 3+ tonsils cover 50-75% of the oropharynx, nearing but not contacting the uvula. This is close but inaccurate, as the finding shows full contact, warranting the higher 4+ grade for precise documentation of this advanced tonsillar size fully.
Correct Answer is C
Explanation
Choice A reason: Thin, gray-white discharge suggests infection like bacterial vaginosis, not menopause. Menopause features dryness, not discharge, making this unrelated to hormonal decline, excluding it as a trigger for menopause education in this case fully here.
Choice B reason: Urinary difficulty may relate to aging or prolapse, not directly menopause. While estrogen loss can affect the urethra, it’s less specific than vaginal symptoms, rendering it secondary for menopause-focused education entirely and accurately here.
Choice C reason: Irregular bleeding and vaginal dryness are hallmark menopause signs, from estrogen drop. Perimenopause causes erratic periods, and dryness reflects atrophy, making this the key finding for targeted menopause education comprehensively and accurately here.
Choice D reason: Painless vaginal lumps suggest cysts or tumors, not menopause. These structural issues lack hormonal ties to estrogen decline, excluding them as menopause indicators needing education compared to bleeding and dryness fully here entirely.
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