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 D

Explanation

A) Occurs only in the clinical area: Focused assessments can be conducted in various settings, including outpatient clinics, home health visits, and emergency departments. Thus, this statement does not accurately define the difference.

B) Involves all body systems: A focused assessment is specifically targeted and does not involve an evaluation of all body systems. Instead, it concentrates on particular areas of concern, making this statement incorrect.
C) Covers the body from head to toe: This describes a comprehensive assessment rather than a focused one. A comprehensive assessment is thorough and covers the entire body, while a focused assessment zeroes in on specific issues or symptoms.

D) More in depth on specific issues: A focused assessment is designed to gather detailed information about particular health problems or concerns rather than providing a broad overview of the patient’s overall health. This targeted approach allows healthcare providers to identify and address specific needs effectively, making this the correct choice.

A. Stiff neck and shoulder pain B. Cauda equina syndrome C. Changes in knee and ankle reflexes D. Sciatica

Correct Answer is A

Explanation

A) Stiff neck and shoulder pain: This symptom is very common in clients with a herniated cervical disc. The herniation can lead to irritation or compression of nearby nerves, resulting in localized pain in the neck and shoulder region. Clients often report this discomfort as one of their primary concerns.

B) Cauda equina syndrome: This serious condition arises from compression of the cauda equina, which occurs in the lower lumbar region of the spine, not the cervical area. Therefore, it is not a typical symptom of a cervical disc herniation.

C) Changes in knee and ankle reflexes: These changes are more associated with lumbar spine issues. While cervical disc problems can affect reflexes, they typically do not present as changes in lower limb reflexes, which are primarily linked to lower back conditions.

D) Sciatica: This term usually refers to pain that radiates down the leg due to compression of the sciatic nerve, often associated with lumbar disc herniation. It is not a common symptom of cervical disc herniation, which affects the neck and upper extremities.

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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

What makes a focused assessment different from a comprehensive assessment?

Correct Answer is D

Explanation

Which condition or symptom is most common in clients with a herniated cervical disc?

Correct Answer is A

Explanation

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