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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
Choice A rationale:
Measuring the amount of aspirate in the NG tube is one way to verify the placement of the tube. Aspirate should be tested for color, pH, and other characteristics to ensure proper positioning.
Choice B rationale:
Flushing the tube with tap water doesn't directly verify tube placement. This action might inadvertently introduce air into the tube, potentially leading to inaccurate assessment results.
Choice C rationale:
Examining the color of aspirated secretions is an essential step in verifying tube placement. Different colors of aspirate can indicate different anatomical locations, helping to ensure the tube is properly positioned.
Choice D rationale:
Measuring the pH of the client's aspirate is another important method to verify NG tube placement. Gastric aspirate tends to be acidic, while respiratory aspirate is usually more alkaline.
Choice E rationale:
Obtaining an x-ray of the client's chest and abdomen is a definitive method for confirming NG tube placement. It provides direct visualization of the tube's location and ensures accuracy.
Correct Answer is B
Explanation
Choice A rationale:
Providing a cup of hot chocolate prior to bedtime is not a suitable intervention for a client reporting difficulty sleeping. Hot chocolate contains caffeine, which can act as a stimulant and interfere with sleep. Caffeine is known to disrupt sleep patterns and should be avoided close to bedtime.
Choice B rationale:
Scheduling exercise activities at least 3 hours before bedtime is the correct intervention for a client experiencing difficulty sleeping. Regular exercise promotes better sleep quality by helping to regulate the sleep-wake cycle and improve sleep duration. However, exercising too close to bedtime can have a stimulating effect, making it harder for the client to fall asleep. By scheduling exercise activities earlier in the day, the client's body will have sufficient time to wind down before bedtime, leading to improved sleep.
Choice C rationale:
Keeping soft music playing at bedtime and throughout the night might not be effective for everyone. While soft music can create a calming environment and help some individuals relax, it may not address the underlying causes of the client's difficulty sleeping. Additionally, some people might find background noise disruptive to their sleep. Therefore, this option might not be as effective as adjusting the timing of exercise.
Choice D rationale:
Scheduling mealtime 2 hours before bedtime is generally a good practice, but it might not directly address the client's reported difficulty sleeping. Consuming heavy or spicy meals close to bedtime can cause discomfort and indigestion, which might interfere with sleep. However, adjusting mealtime alone might not be sufficient to resolve the client's sleep issues, especially if other factors are contributing to their insomnia.
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