During the performance of a Romberg test, the nurse observes the client sway slightly. What action should the nurse take?
Follow up by having the client perform the Rinne test
Reposition the client supine to ensure safety.
Document successful completion of the assessment.
Facilitate a referral to a neurologist.
The Correct Answer is C
Choice A rationale
The Rinne test is a hearing test used to evaluate the difference between sound transmission through air conduction versus bone conduction. It is not typically used following a Romberg test, which evaluates balance.
Choice B rationale
While ensuring the patient’s safety is always important, repositioning the client supine is not the typical response to slight swaying during a Romberg test.
Choice C rationale
Slight swaying during a Romberg test is considered normal. Therefore, documenting successful completion of the assessment would be the appropriate action.
Choice D rationale
A referral to a neurologist is not typically necessary for slight swaying during a Romberg test, as this is considered within normal limits.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is: = b. Prostaglandins
Choice A: Carbonic anhydrase inhibitors: These medications can be used for glaucoma, but they are not typically the first-line treatment due to potential side effects.
Choice B: Prostaglandins (Correct Answer) These are often the preferred initial medication for glaucoma because they are effective at lowering eye pressure, have minimal systemic side effects, and are typically used once daily.
Choice C: Alpha-agonists: These medications can be used as an adjunct to other glaucoma medications but are not usually the first choice due to potential side effects like dry mouth and fatigue.
Choice D: Beta-blockers: While once a common first-line treatment, beta-blockers have been largely replaced by prostaglandins due to potential side effects like slowed heart rate and worsened breathing problems.
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale
Introducing oneself after entering the patient’s room is a key aspect of effective communication with a blind patient. This helps the patient identify who is in the room with them.
Choice B rationale
Using a firm, loud voice when addressing the patient is not necessarily effective. While it’s important to speak clearly, raising one’s voice can come off as patronizing or disrespectful. It’s better to speak in a normal tone and adjust as needed based on the patient’s feedback.
Choice C rationale
Lightly touching the patient’s arm can be an effective way to gain their attention, especially if they may not have heard you enter the room. However, it’s important to ask for consent before touching the patient.
Choice D rationale
Providing instructions in clear, simple terms can be very helpful for a blind patient. This can help them understand what is happening and what they need to do.
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