The nurse notes that a client has ataxi
Plantar flexion
Romberg
Achilles reflex
Patellar reflex
The Correct Answer is B
Choice A reason: Plantar flexion is not a test that the nurse uses to gain more information about this client's gait because it is a movement of the foot that points the toes downward, not a measure of balance or coordination.
Choice B reason: Romberg is a test that the nurse uses to gain more information about this client's gait because it is a measure of balance and proprioception, which are often impaired in ataxiA. The test involves asking the client to stand with their feet together and arms at their sides, first with their eyes open and then with their eyes closed, while observing for swaying or fallinG.
Choice C reason: Achilles reflex is not a test that the nurse uses to gain more information about this client's gait because it is a measure of the reflex response of the calf muscle when the Achilles tendon is tapped, not a measure of balance or coordination.
Choice D reason: Patellar reflex is not a test that the nurse uses to gain more information about this client's gait because it is a measure of the reflex response of the quadriceps muscle when the patellar tendon is tapped, not a measure of balance or coordination.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
Choice A reason: Asking how they are managing at home is an appropriate action by the nurse because it shows interest and respect for the client's situation, needs, and preferences.
Choice B reason: Going automatically into the client's bedroom is not an appropriate action by the nurse because it violates the client's privacy and autonomy. The nurse should ask for permission before entering any room in the client's homE.
Choice C reason: Arranging mutual future visits is an appropriate action by the nurse because it demonstrates collaboration and continuity of care with the client.
Choice D reason: Thanking the client for arranging a home visit is not an appropriate action by the nurse because it implies that the nurse is doing a favor for the client, rather than providing professional servicE.
Choice E reason: Sitting down and discussing with the client and family members is an appropriate action by the nurse because it facilitates communication, rapport, and education with the client and their support system.
Correct Answer is D
Explanation
Choice A reason: The client's financial resources are not the most important factor for the nurse to consider because Meals-on-Wheels is a program that provides low-cost or free meals to seniors and people with disabilities who are unable to cook or shop for themselves.
Choice B reason: The client's level of family support is not the most important factor for the nurse to consider because Meals-on-Wheels is a program that aims to reduce social isolation and improve nutrition for homebound clients, regardless of their family situation.
Choice C reason: The client's access to transportation is not the most important factor for the nurse to consider because Meals-on-Wheels is a program that delivers meals directly to the client's home, eliminating the need for transportation.
Choice D reason: The client's ability to prepare meals is the most important factor for the nurse to consider because Meals-on-Wheels is a program that caters to clients who have difficulty or inability to cook or shop for themselves due to physical, mental, or environmental limitations.
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