A nurse is preparing a client for a Romberg test. Which of the following statements should the nurse make?
"Stand with your feet together and your arms at your sides.”
"After I place the tuning fork, tell me when you no longer hear the sound.”
"I'm going to stroke the lateral side of the bottom of your foot.”
"Touch each fingertip as quickly as possible with your thumb.”
The Correct Answer is A
The correct answer is choice A: "Stand with your feet together and your arms at your sides."
Choice A rationale:
This statement is correct. The nurse should instruct the client to stand with their feet together and their arms at their sides for a Romberg test. This position helps to assess the client's ability to maintain balance with minimal sensory input, evaluating their proprioception and vestibular function.

Choice B rationale:
The instruction about the tuning fork is unrelated to the Romberg test. The tuning fork is commonly used to assess hearing and vibratory sensations, not balance.
Choice C rationale:
This statement is unrelated to the Romberg test. Mentioning the lateral side of the foot suggests a neurological examination related to assessing reflexes, such as the Babinski reflex.
Choice D rationale:
This instruction pertains to a different test known as the "finger-to-nose" test, which is used to assess coordination, not balance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D: "Instruct the client to tilt their head forward while eating."
Choice A rationale:
Offering the client a straw to drink liquids might not be suitable for someone with dysphagia following a stroke. Straws can sometimes contribute to aspiration risk, especially if the client has difficulty controlling their swallowing reflex. Using a straw might lead to aspiration of liquids, which can be dangerous for the client's respiratory health.
Choice B rationale:
Placing food toward the back of the client's mouth could increase the risk of choking and aspiration, especially if the client has difficulty swallowing due to dysphagia. It's important to place small bites of food at the front of the mouth and encourage slow, controlled chewing and swallowing to reduce the risk of aspiration.
Choice C rationale:
Encouraging the client to lie down and rest for 30 minutes after meals is not a recommended intervention for someone with dysphagia. This position can actually increase the risk of aspiration. The client should be in an upright position while eating and for some time after eating to allow gravity to assist in preventing aspiration.
Choice D rationale:
Instructing the client to tilt their head forward while eating helps to facilitate safer swallowing by preventing food from entering the airway. This posture helps direct the food toward the esophagus and reduces the risk of aspiration. It's an essential technique for clients with dysphagia to maintain their airway safety while eating.
Correct Answer is B
Explanation
The correct answer is: B. Latex.
Choice A reason: Allergy to eggs is primarily a concern when it comes to vaccinations, such as the influenza vaccine, which may contain egg protein. In the context of IV therapy, egg allergies are not typically associated with direct contraindications or precautions. However, it’s important to note that some medications or vaccines may contain egg proteins, which could be relevant in certain medical procedures, but not usually in standard IV therapy.
Choice B reason: Latex allergies are particularly relevant in a hospital setting where latex is commonly found in various medical supplies, including gloves, catheters, and IV tubing. A latex allergy can cause severe reactions, including anaphylaxis, which is a life-threatening condition. Therefore, it is crucial for healthcare providers to be aware of a patient’s latex allergy to avoid exposure during medical procedures, including IV therapy.
Choice C reason: Seafood allergies are generally related to the ingestion of seafood and do not typically pose a risk in the context of IV therapy. The concern about iodine in contrast media, which is sometimes mistakenly linked to seafood allergies, is not relevant to standard IV therapy solutions.
Choice D reason: Bee sting allergies are significant when a patient is exposed to bee venom, which can cause anaphylaxis. In the context of IV therapy, a bee sting allergy is not typically a concern unless the therapy involves venom immunotherapy or the patient has had a recent bee sting that might complicate their medical condition.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
