Nokea
The nurse is caring for the client who is having difficulty walking. Which procedure should the nurse perform to test the cerebellar function of the client?
- A. With the client’s eyes shut, ask whether the touch with a cotton applicator is sharp or dull.
- B. Ask the client to close the eyes, then hold hands with palms up perpendicular to the body.
- C. Ask the client to grasp and squeeze, with each hand at the same time, the hands of the nurse.
- D. Have the client place the hands on the thighs, then quickly turn the palms up and then down.
Correct Answer: D
Rationale: Detecting sharp or dull touch is a test for peripheral nerve function. Assessing for pronator drift is a test for muscle weakness due to cerebral or brainstem dysfunction. Assessment of hand grasps compares equality of muscle strength bilaterally. Repetitive alternating motion tests the client’s coordination, an indicator of cerebellar function.
You may also like to solve these questions
Which intervention should be added to the client's care plan in relation to this latest finding?
- A. Have the client wear dark glasses when in bright light.
- B. Cover the client's affected eye with an eye patch.
- C. Approach the client from the unaffected side.
- D. Position food on the tray resembling the face of a clock.
Correct Answer: C
Rationale: Approaching from the unaffected side ensures the client with hemianopia can see the nurse, compensating for visual field loss.
Which instruction should be the nurse's priority in this situation?
- A. Steps to enhance the client's immune system
- B. Importance of maintaining a balanced diet
- C. Techniques to improve the client's safety
- D. Importance of social interactions
Correct Answer: C
Rationale: Safety is the priority for clients with Parkinson's disease due to risks of falls and injury from motor symptoms.
Which nursing task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel?
- A. Teach Credé’s maneuver to the client needing to void.
- B. Administer the tube feeding to the client who is quadriplegic.
- C. Assist with bowel training by placing the client on the bedside commode.
- D. Observe the client demonstrating self-catheterization technique.
Correct Answer: C
Rationale: Assisting with bowel training by placing the client on a commode (C) is within the UAP’s scope, involving physical assistance. Teaching (A), administering tube feedings (B), and observing techniques (D) require nursing judgment and are not delegable.
The nurse is caring for several clients on a medical unit. Which client should the nurse assess first?
- A. The client with ALS who is refusing to turn every two (2) hours.
- B. The client with abdominal pain who is complaining of nausea.
- C. The client with pneumonia who has a pulse oximeter reading of 90%.
- D. The client who is complaining about not receiving any pain medication.
Correct Answer: C
Rationale: A pulse oximetry of 90% (C) indicates hypoxemia, requiring immediate assessment to prevent respiratory compromise. Refusing turning (A), nausea (B), and pain complaints (D) are less urgent.
Which client statement indicates a need for further teaching about post-craniotomy care?
- A. I'll avoid coughing forcefully.'
- B. I'll sleep with my head elevated.'
- C. I can lift heavy objects after a week.'
- D. I'll report severe headaches immediately.'
Correct Answer: C
Rationale: Lifting heavy objects post-craniotomy can increase intracranial pressure; clients should avoid this for several weeks.