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.

Answer and Explanation

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

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Correct Answer is A

Explanation

Choice A rationale

Facial droop is a classic symptom of stroke. It occurs when there’s weakness or paralysis on one side of the face, which is caused by a disruption in the nerve signals due to a stroke. This can be easily observed in the person’s smile, as it will appear uneven.
Choice B rationale
While dysrhythmias can be associated with stroke, they are not the most indicative symptom. Dysrhythmias are more commonly associated with heart conditions.
Choice C rationale
Periorbital edema, or swelling around the eyes, is not typically a symptom of stroke. It can be caused by various conditions such as allergies, infections, or kidney problems.
Choice D rationale
Projectile vomiting is not typically a symptom of stroke. It can be caused by various conditions such as gastrointestinal issues, brain tumors, or increased intracranial pressure.

Correct Answer is ["35 "]

Explanation

Step 1 is to calculate the total daily dosage in milligrams. This is done by multiplying the weight of the client by the ordered daily dosage. So, 70 kg × 25 mg/kg = 1750 mg/day.

Step 2 is to divide the total daily dosage by the number of doses per day to get the dosage per dose. So, 1750 mg ÷ 2 = 875 mg/dose.

Step 3 is to calculate the volume of the dose in milliliters. The supply of Amoxicillin is 125 mg/5 mL, which means there are 125 mg of Amoxicillin in every 5 mL. So, to find out how many milliliters contain 875 mg, we set up a proportion: (125 mg / 5 mL) = (875 mg / x mL). Solving for x gives x = (875 mg × 5 mL) ÷ 125 mg = 35 mL. Therefore, the correct dosage for one dose is 35 mL.

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During the performance of a Romberg test, the nurse observes the client sway slightly. What action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a patient with a suspected stroke. What assessment finding is most suggestive of a stroke?

Correct Answer is A

Explanation

Correct Answer is ["35 "]

Explanation

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