The nurse is caring for a client who was admitted to the medical unit. The healthcare provider states that the client's Romberg test is positive. In order to meet this client's elimination needs, which intervention will the nurse implement?

Obtain an order for a catheter

Allow the client to walk independently

Obtain a bedside commode

Limit fluid intake

Answer and Explanation

The Correct Answer is C

A) Obtain an order for a catheter: While catheterization can help manage elimination needs, it is generally considered a more invasive approach and is not the first line of action unless absolutely necessary. The goal should be to maintain the client’s dignity and encourage as much independence as safely possible.

B) Allow the client to walk independently: Given that the Romberg test is positive, indicating potential balance issues, allowing the client to walk independently could increase the risk of falls and injury. Safety is a primary concern in this situation.

C) Obtain a bedside commode: This intervention is appropriate as it provides a safe and accessible option for the client to meet their elimination needs without the need to navigate to a bathroom, which may be challenging given their balance issues. A bedside commode allows for easier access while minimizing the risk of falls.

D) Limit fluid intake: Limiting fluid intake is not a safe or effective way to address elimination needs and could lead to dehydration and other complications. Encouraging appropriate fluid intake is important for overall health, provided the client can manage elimination safely.

Nursing Test Bank

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Correct Answer is C

Explanation

A) Anterior to the elbow: This term describes a location in front of the elbow. While it indicates a direction, it does not specifically address the vertical relationship of the discomfort in relation to the elbow. Since the client described discomfort "above" the elbow, this term is not the most accurate choice.
B) Distal to the elbow: The term "distal" refers to a location that is farther away from the trunk of the body or point of reference. Given that the discomfort is described as being above the elbow, this term is incorrect, as it would imply the discomfort is located toward the hand rather than toward the shoulder.
C) Proximal to the elbow: This term correctly indicates a location closer to the trunk of the body and specifically suggests that the discomfort is situated above the elbow, making it the most appropriate medical terminology to use in this context. It accurately reflects the relationship of the discomfort to the elbow.
D) Inferior to the elbow: "Inferior" refers to a location below another point of reference. Since the discomfort is described as above the elbow, this terminology would not apply and would misrepresent the location of the client’s discomfort.

A. Interrupt with frequent questions B. Answer slowly and be confused C. Withdraw from strangers D. Take longer to respond and react

Correct Answer is D

Explanation

A) Interrupt with frequent questions: While older adults may have questions, they typically do not interrupt frequently. This behavior is more indicative of anxiety or agitation rather than a cognitive change associated with aging.

B) Answer slowly and be confused: While some older adults may exhibit slower responses, confusion is not a normal cognitive change associated with aging. Confusion may suggest underlying issues such as delirium or dementia, rather than typical age-related cognitive changes.

C) Withdraw from strangers: Social withdrawal can occur in some older adults, but it is not a universal expectation. Many older adults remain engaged and sociable, and withdrawal is more commonly associated with mental health issues rather than cognitive changes.

D) Take longer to respond and react: It is common for older adults to take longer to process information and respond due to normal cognitive slowing. This may reflect changes in processing speed rather than a decline in cognitive function, and it is an expected part of aging.

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The nurse is caring for a client who was admitted to the medical unit. The healthcare provider states that the client's Romberg test is positive. In order to meet this client's elimination needs, which intervention will the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client tells the nurse that they are experiencing discomfort above their elbow. Which medical terminology should the nurse use to describe the location of discomfort?

Correct Answer is C

Explanation

Based on an understanding of the cognitive changes that normally occur with aging. what would the nurse expect a newly hospitalized older adult to do?

Correct Answer is D

Explanation

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