The nurse is preparing a client for a neurological examination by the health care provider and explains tests the health care provider will be doing, including the Romberg test. The client asks the purpose of this particular test.

The correct reply by the nurse is which of the following?

Choice A rationale

Administering a bolus of normal saline addresses fluid volume but does not directly address the respiratory effort increase or potential increased ICP, which is the most concerning aspect of the head injury.

Choice B rationale

Administering bronchodilators and monitoring LOC may help with respiratory issues but does not address the underlying problem of increased ICP, which could be causing the increased respiratory effort.

Choice C rationale

Increasing the client's bed height and reassessing in 30 minutes might temporarily help, but it is not the most immediate and appropriate intervention. The client’s symptoms suggest a more urgent issue.

Choice D rationale

Informing the care team and assessing for further signs of increased ICP is crucial. Increased respiratory effort in a client with head injury can indicate rising intracranial pressure, which requires immediate medical attention to prevent further complications.

Choice A rationale

Onychocryptosis, also known as an ingrown toenail, is a condition where the edge of the toenail grows into the surrounding skin. This can cause pain, swelling, and sometimes infection. It is not related to a dermatophyte infection, which is a fungal infection affecting the toenail.

Choice B rationale

Pediculosis refers to an infestation of lice, which are small parasitic insects that feed on human blood. It typically affects areas like the scalp, body, and pubic region but not the toenails. Pediculosis is not related to fungal infections.

Choice C rationale

Tinea pedis, commonly known as athlete's foot, is a fungal infection that primarily affects the skin on the feet, particularly between the toes. While it is a dermatophyte infection, it does not specifically affect the toenails.

Choice D rationale

Onychomycosis is a fungal infection of the toenails or fingernails. It is caused by dermatophytes, yeasts, or nondermatophyte molds. The infection leads to thickened, brittle, and discolored nails, which accurately describes a dermatophyte infection of the toenail.