A nurse is conducting a Romberg test as part of a patient’s physical assessment. Which of the following methods should the nurse employ?
Touch the patient’s face with a cotton ball.
Apply a vibrating tuning fork to the patient’s forehead.
Have the patient stand with their arms at their sides and their feet together.
Perform direct percussion over the area of the kidneys.
The Correct Answer is C
Choice A rationale
Touching the patient’s face with a cotton ball is not part of the Romberg test. This action is more commonly associated with tests of facial sensation.
Choice B rationale
Applying a vibrating tuning fork to the patient’s forehead is not part of the Romberg test. This action is more commonly associated with tests of vibratory sensation.
Choice C rationale
Having the patient stand with their arms at their sides and their feet together is the correct method for conducting a Romberg test.
Choice D rationale
Performing direct percussion over the area of the kidneys is not part of the Romberg test. This action is more commonly associated with tests of kidney function or the presence of kidney disease.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
The correct answers are Choices A, B, and C.
Choice A rationale: Passive range-of-motion exercises should be performed more frequently than once each day to maintain joint mobility, prevent contractures, and stimulate circulation. Performing them only once daily is inadequate for a client with paraplegia who is immobile.
Choice B rationale: Nonblanchable erythema is a sign of a stage 1 pressure ulcer, indicating that the skin is at risk of further breakdown and infection. Immediate intervention is required to prevent progression to more severe pressure injuries.
Choice C rationale: Plantar flexion contractures can lead to significant long-term disability and complications, such as difficulty in ambulation and pain. These contractures require intervention through more frequent range-of-motion exercises, splinting, or physical therapy to prevent worsening.
Choice D rationale: Pedal pulses that are 2+ bilaterally are within normal limits and indicate adequate peripheral circulation. This finding does not require intervention.
Correct Answer is C
Explanation
Choice A rationale
While the top of the cane should be parallel to the client’s greater trochanter, this alone does not indicate correct use of the cane.
Choice B rationale
Advancing the cane 46 cm (18 in) forward while walking is too far. To maintain balance, the client should advance the cane about 15-30 cm (6-12 in) at a time.
Choice C rationale
The client should hold the cane on the stronger side of their body to increase support and maintain alignment. This is an indication of correct use.
Choice D rationale
The client should move their weaker leg forward with the cane. This divides the client’s body weight between the cane and the stronger leg.
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