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A nurse assesses a client who demonstrates a positive Romberg's sign with eyes closed but not with eyes open. Which condition is most likely?
- A. Difficulty with proprioception
- B. Peripheral motor disorder
- C. Impaired cerebral function
- D. Positive pronator drift
Correct Answer: A
Rationale: A positive Romberg's sign with eyes closed but not with eyes open indicates difficulty with proprioception, as the client relies on vision to compensate for impaired position sense. The other options do not specifically describe this clinical finding.
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A nurse delegates care for a client with cranial nerve II impairment to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this client's care?
- A. Tell the client where food items are on the meal tray.
- B. Assist the client with ambulation to the bathroom.
- C. Check the client's skin for pressure ulcers daily.
- D. Provide the client with a whiteboard to communicate.
Correct Answer: A
Rationale: Cranial nerve II (optic nerve) impairment causes vision loss, so describing food placement on the tray helps the client eat independently. The other options address unrelated issues like mobility or communication.
A nurse teaches a client who is scheduled for a positron emission tomography scan of the brain. Which statement should the nurse include in this client's teaching?
- A. Avoid caffeine-containing substances for 12 hours before the test.
- B. Increase your fluid intake before and after the test.
- C. Do not take your cardiac medication the morning of the test.
- D. Remove your dentures and any metal before the test begins.
Correct Answer: A
Rationale: Caffeine is a central nervous system stimulant that may alter PET scan results, so it should be avoided for 12 hours prior. Increased fluid intake is unnecessary, cardiac medications should be continued, and metal removal is relevant for MRI, not PET.
A nurse teaches an 80-year-old client with diminished touch sensation. Which statement should the nurse include in this client's teaching?
- A. Place items in warm water to increase your circulation.
- B. Bathe in warm water to increase your circulation.
- C. Look at the placement of your feet when walking.
- D. Walk barefoot to decrease pressure effects from your shoes.
Correct Answer: C
Rationale: Older clients with decreased sensation are at risk of injury from the inability to sense changes in terrain when walking. Instructing the client to look at the placement of their feet compensates for this sensory loss and reduces fall risk. Warm water poses a risk of thermal injury, and walking barefoot increases the risk of injury due to lack of protection.
A nurse cares for a client who is experiencing deteriorating neurologic function. The client states, 'I am worried I will not be able to care for my young children.' How should the nurse respond?
- A. Caring for your children is a priority. You may not want to ask for help, but you have to.
- B. Our community has resources that may help you with household tasks so you have energy to care for your children.
- C. You seem distressed. Would you like to talk to a psychologist about adjusting to your changing status?
- D. Give me more information about what worries you, so we can see if we can do something to make adjustments.
Correct Answer: D
Rationale: Exploring the client's specific concerns allows the nurse to tailor interventions and provide appropriate support. The other options make assumptions or suggest solutions without fully understanding the client's needs.
A nurse cares for a client who is recovering from a single-photon emission computed tomography (SPECT) with a radiopharmaceutical agent. Which statement should the nurse include when discussing the plan of care with this client?
- A. You may return to your previous activity level immediately.
- B. You are radioactive and must use a private bathroom.
- C. Frequent assessments of the injection site will be completed.
- D. We will be monitoring your renal function closely.
Correct Answer: A
Rationale: No special precautions are needed after SPECT, as radioisotopes are eliminated in urine without requiring monitoring or activity restrictions. The other options are unnecessary.