A nurse is performing a focused assessment of a client's sensory functions. Which of the following tests should the nurse perform?

Walking gait test.

Plantar reflex test.

Finger-to-nose test.

Romberg test.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

The walking gait test is used to assess a client's walking pattern and balance, particularly for identifying abnormalities in gait. However, it doesn't specifically evaluate sensory functions, making it an inappropriate choice for this scenario.

Choice B rationale:

The plantar reflex test, also known as the Babinski reflex test, assesses the neurological integrity of the corticospinal tract. It involves stimulating the sole of the foot to elicit specific reflex movements. While this test is important in assessing neurological function, it doesn't directly evaluate sensory functions as requested in the question.

Choice C rationale:

The finger-to-nose test is a part of the neurological examination used to assess a client's coordination and proprioception. In this test, the client is asked to touch their nose with their index finger while alternating between eyes closed and eyes open. This evaluates their ability to sense the position of their limbs in space (proprioception) and their coordination. It directly addresses the focus of the question, making it the correct choice.

Choice D rationale:

The Romberg test evaluates a client's balance and proprioception. It involves having the client stand with their feet together and their eyes closed to assess their ability to maintain balance without visual input. While this test is relevant to sensory functions, it primarily assesses proprioception and balance rather than coordination, which the question is specifically targeting.

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Correct Answer is B

Explanation

Choice A rationale:

1 cup of shredded lettuce is low in potassium and is not the best source of potassium for a client with heart failure. While vegetables like lettuce are generally healthy, they do not provide a significant amount of potassium.

Choice B rationale:

1 cup of cantaloupe is the best source of potassium among the given options. Cantaloupe is a fruit that contains a moderate amount of potassium. Including this fruit in the client's diet can help maintain a balanced potassium level, which is important for heart health.

Choice C rationale:

1 oz of tuna is a source of protein but is not particularly rich in potassium. While protein intake is important for overall health, other choices on the list provide more potassium, which is specifically needed for clients with heart failure.

Choice D rationale:

1 cup of raspberries is a good source of fiber and antioxidants, but it is not as rich in potassium as cantaloupe. While raspberries can be a healthy addition to the diet, they are not the best choice for addressing potassium needs in this scenario.

A. Place a sterile kit on the overbed table above waist level. B. Open the outermost flap of the sterile kit toward their body. C. Turn their back to the sterile field when coughing during the procedure. D. Hold a package of sterile gauze 30.5 cm (12 in) above the sterile field when dropping the gauze onto the field.

Correct Answer is A

Explanation

The correct answer is Choice A.

Choice A rationale: Placing a sterile kit on the overbed table above waist level maintains the sterility of the field. This position ensures that the kit is not contaminated by lower surfaces or inadvertent touch, which is essential for preventing infection during dressing changes.

Choice B rationale: Opening the outermost flap of the sterile kit toward their body increases the risk of contaminating the sterile field. The first flap should be opened away from the body to maintain the sterility of the field and prevent contamination.

Choice C rationale: Turning their back to the sterile field when coughing is incorrect because it increases the risk of contamination. The nurse should step away from the sterile field and cough into their elbow or use a mask to maintain sterility.

Choice D rationale: Holding a package of sterile gauze 30.5 cm (12 in) above the sterile field when dropping the gauze onto the field is too high and increases the risk of contamination. The gauze should be held closer, approximately 6 inches above the field, to ensure accuracy and sterility.

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A nurse is performing a focused assessment of a client's sensory functions. Which of the following tests should the nurse perform?

Nursing Test Bank

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