The nurse notes that a client has ataxi

Plantar flexion

Romberg

Achilles reflex

Patellar reflex

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason: Hypertension is a manifestation of increased intracranial pressure because it is part of the Cushing's triad, which is a set of signs that indicate increased intracranial pressure and impaired cerebral perfusion. The other signs of Cushing's triad are bradycardia and irregular respirations.

Choice B reason: Tinnitus is not a manifestation of increased intracranial pressure because it is a symptom of hearing loss, ear infection, or ear damage, not increased intracranial pressurE. Tinnitus is a ringing, buzzing, or hissing sound in the ears that can be caused by various factors such as exposure to loud noise, aging, or medication side effects.

Choice C reason: Hypotension is not a manifestation of increased intracranial pressure because it is a sign of decreased blood pressure, not increased intracranial pressurE. Hypotension can be caused by various factors such as dehydration, blood loss, or shock.

Choice D reason: Tachycardia is not a manifestation of increased intracranial pressure because it is a sign of increased heart rate, not increased intracranial pressurE. Tachycardia can be caused by various factors such as anxiety, fever, or pain.

A. "Diet and exercise are good for you and good for your heart." B. "It's not unusual to feel that way at first, but once you learn the routine, you'll enjoy it." C. "Cardiac rehabilitation cannot undo the damage to your heart, but it can help you get back to your previous level of activity safely." D. "Your doctor is the expert here, and I'm sure he would only recommend what is best for you."

Correct Answer is C

Explanation

Choice A reason: "Diet and exercise are good for you and good for your heart." This response is true, but it does not address the client's concern or provide any specific information about cardiac rehabilitation.

Choice B reason: "It's not unusual to feel that way at first, but once you learn the routine, you'll enjoy it." This response is empathetic, but it does not explain the benefits or goals of cardiac rehabilitation.

Choice C reason: "Cardiac rehabilitation cannot undo the damage to your heart, but it can help you get back to your previous level of activity safely." This response is accurate and informativE. It acknowledges the client's condition and provides realistic expectations about cardiac rehabilitation.

Choice D reason: "Your doctor is the expert here, and I'm sure he would only recommend what is best for you." This response is respectful, but it does not answer the client's question or encourage their participation in cardiac rehabilitation.

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The nurse notes that a client has ataxi

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Explanation

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Correct Answer is C

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