The nurse is performing the Romberg test on a client during a neurological assessment. Which of the following best describes the rationale for conducting the Romberg test?

To measure respiratory rate and depth.

To evaluate coordination and fine motor skills.

To test for proprioception and vestibular function.

To assess cranial nerve function related to facial expression.

Answer and Explanation

The Correct Answer is C

Choice A reason:

The Romberg test is not used to measure respiratory rate and depth. Respiratory assessments involve observing breathing patterns, rate, and depth, which are unrelated to the Romberg test.

Choice B reason:

While the Romberg test can provide some information about coordination, its primary purpose is not to evaluate fine motor skills. Fine motor skills are typically assessed through tasks that involve precise hand and finger movements.

Choice C reason:

The Romberg test is used to test for proprioception and vestibular function. It assesses the client’s ability to maintain balance with their eyes closed, which helps identify issues with proprioception (the sense of body position) and vestibular function (the inner ear’s role in balance).

Choice D reason:

The Romberg test does not assess cranial nerve function related to facial expression. Cranial nerve assessments involve specific tests for each nerve, such as asking the client to smile or raise their eyebrows to evaluate facial nerve function.

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Correct Answer is B

Explanation

Choice A reason:

A gradual onset of headache is more characteristic of other types of headaches or conditions, such as tension headaches or migraines. Hemorrhagic strokes, particularly those caused by a ruptured cerebral aneurysm, typically present with a sudden and severe headache, often described as the “worst headache of my life.” This sudden onset is due to the rapid accumulation of blood in the brain, which increases intracranial pressure and causes immediate symptoms.

Choice B reason:

Changes in consciousness are a common manifestation of a hemorrhagic stroke. The sudden bleeding into the brain can disrupt normal brain function, leading to symptoms such as confusion, lethargy, or loss of consciousness. These changes occur rapidly and are a key indicator of a serious neurological event. The nurse should be vigilant for any alterations in the client’s level of consciousness, as this can signify worsening of the condition and the need for immediate medical intervention.

Choice C reason:

A gradual onset of several hours is not typical for hemorrhagic strokes. These strokes usually present with sudden and severe symptoms due to the abrupt rupture of a blood vessel in the brain. The rapid increase in intracranial pressure from the bleeding causes immediate and severe symptoms, rather than a slow progression over hours.

Choice D reason:

A history of neurologic deficits lasting less than 1 hour is more indicative of a transient ischemic attack (TIA), also known as a mini-stroke. TIAs are temporary and resolve within a short period without causing permanent damage. In contrast, a hemorrhagic stroke caused by a ruptured cerebral aneurysm results in immediate and severe symptoms that do not resolve quickly and require urgent medical attention.

A. The assistive personnel’s ability to complete the task without assistance. B. The assistive personnel’s level of experience and competency in performing the task. C. The assistive personnel’s rapport with clients. D. The assistive personnel’s availability at the time of the delegation.

Correct Answer is B

Explanation

Choice A reason:

The assistive personnel’s ability to complete the task without assistance is important, but it is encompassed within the broader consideration of their competency and experience. Ensuring that the personnel can perform the task independently is part of assessing their overall capability.

Choice B reason:

The assistive personnel’s level of experience and competency in performing the task is a critical factor in the delegation process. The nurse must ensure that the personnel have the necessary skills and knowledge to perform the task safely and effectively. This consideration aligns with the “right person” aspect of the five rights of delegation, ensuring that the task is delegated to someone who is qualified to perform it.

Choice C reason:

The assistive personnel’s rapport with clients is beneficial for providing compassionate care, but it is not a primary consideration in the delegation process. The focus should be on the personnel’s ability to perform the task competently and safely.

Choice D reason:

The assistive personnel’s availability at the time of the delegation is a logistical consideration, but it does not address the critical aspect of competency. While availability is necessary, it is secondary to ensuring that the personnel are capable of performing the task.

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The nurse is performing the Romberg test on a client during a neurological assessment. Which of the following best describes the rationale for conducting the Romberg test?

Nursing Test Bank

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