Nokea
A nurse is performing a neurosensory examination for a client. Which of the following tests should the nurse perform to test the client's balance? Select all.
- A. Romberg test
- B. Heel-to-toe walk
- C. Snellen test
- D. Spinal accessory function
- E. Rosenbaum test
Correct Answer: A, B
Rationale: The correct tests to assess balance are the Romberg test and heel-to-toe walk. The Romberg test evaluates proprioception and balance by having the client stand with feet together and eyes closed. If the client sways, it indicates balance impairment. The heel-to-toe walk assesses gait and balance by asking the client to walk in a straight line placing the heel of one foot in front of the toes of the other foot. Choices C, D, and E are incorrect as they are not related to balance assessment. The Snellen test evaluates visual acuity, spinal accessory function assesses shoulder movement, and Rosenbaum test measures near vision acuity.
You may also like to solve these questions
A nursing instructor is explaining the various stages of the lifespan to a group of nursing students. The nurse should offer which of the following behaviors by a young adult as an example of appropriate psychosocial development?
- A. Becoming actively involved in providing guidance to the next generation
- B. Adjusting to major changes in roles and relationships due to losses
- C. Devoting a great deal of time to establishing an occupation
- D. Finding oneself 'sandwiched' in between & being responsible for two generations
Correct Answer: C
Rationale: The correct answer is C: Devoting a great deal of time to establishing an occupation. This is an example of appropriate psychosocial development for a young adult as per Erikson's theory of psychosocial development. During the stage of young adulthood, individuals focus on establishing their careers and personal identities. This is a crucial developmental task during this stage, as it helps individuals gain a sense of purpose and direction in life. Choices A, B, and D involve responsibilities and challenges more commonly associated with other stages of life, such as middle adulthood or late adulthood. Therefore, they are not appropriate examples of psychosocial development for a young adult.
A nurse on a med-surg unit has received change-of-shift report & will care for 4 clients. Which of the following client's needs may the nurse assign to assistive personnel (AP)?
- A. Feeding a client who was admitted 24 hrs ago w/aspiration pneumonia
- B. Reinforcing teaching w/a client who is learning to walk using a quad cane
- C. Reapplying a condom catheter for a client who has urinary incontinence
- D. Applying a sterile dressing to a pressure ulcer
Correct Answer: C
Rationale: The correct answer is C because reapplying a condom catheter for a client with urinary incontinence is a task that can be safely delegated to assistive personnel (AP). This task involves a straightforward procedure that does not require advanced nursing skills or critical thinking. The nurse can provide clear instructions and oversee the AP's performance.
Choice A is incorrect because feeding a client with aspiration pneumonia requires close monitoring by a nurse due to the risk of complications. Choice B is incorrect as reinforcing teaching for a client learning to walk with a quad cane involves assessing the client's understanding and progress, which is within the nurse's scope. Choice D is incorrect because applying a sterile dressing to a pressure ulcer requires sterile technique and assessment of wound healing, which should be done by a nurse.
A nurse educator is teaching a module on safe med administration to newly hired nurses. Which of the following statements by the newly hired nurse indicate understanding of the nurse's responsibility when implementing med therapy? Select all.
- A. I will observe for med side effects.
- B. I will monitor for therapeutic effects.
- C. I will prescribe the appropriate dose.
- D. I will change the dose if adverse effects occur.
- E. I will refuse to give a med if I believe it is unsafe.
Correct Answer: A,B,E
Rationale: The correct answers are A, B, and E. A nurse's responsibility in implementing medication therapy includes observing for side effects (A), monitoring for therapeutic effects (B), and refusing to give a medication if they believe it is unsafe (E).
A - Observing for side effects is crucial in ensuring patient safety and prompt intervention if adverse reactions occur.
B - Monitoring for therapeutic effects helps assess the effectiveness of the medication in achieving the desired outcomes for the patient's condition.
E - Refusing to give a medication if the nurse believes it is unsafe demonstrates advocacy for the patient's well-being and adherence to the principles of safe medication administration.
Choices C and D are incorrect because nurses should not prescribe or change medication doses without proper authorization from a prescribing healthcare provider. It is beyond the scope of a nurse's role.
In summary, the correct answers focus on patient safety, monitoring effectiveness, and advocating for the patient's best interest, while the incorrect choices involve actions outside the nurse's scope
A goal for a client who has difficulty w/self-feeding due to rheumatoid arthritis is to use adaptive devices. The nurse caring for the client should initiate a referral w/which of the following members of the interprofessional care team?
- A. Social worker
- B. Certified nursing assistant
- C. Registered dietitian
- D. Occupational therapist
Correct Answer: D
Rationale: The correct answer is D: Occupational therapist. Occupational therapists specialize in helping individuals with physical limitations to maximize their ability to perform daily activities, such as self-feeding. They can assess the client's specific needs, recommend appropriate adaptive devices, and provide training on how to use them effectively. Social workers (A) focus more on psychosocial support, certified nursing assistants (B) provide direct care but may not have the expertise in adaptive devices, and registered dietitians (C) focus on nutrition-related issues. Therefore, the occupational therapist (D) is the most appropriate member of the interprofessional care team to address the client's self-feeding difficulties due to rheumatoid arthritis.
A nurse is caring for a client diagnosed w/severe acute respiratory syndrome (SARS). The nurse is aware that health care professionals are required to report communicable & infectious diseases. Which of the following illustrate the rationale for reporting? Select all.
- A. Planning & evaluating control & prevention strategies
- B. Determining public health priorities
- C. Ensuring proper medical treatment
- D. Identifying endemic disease
- E. Monitoring for common-source outbreaks
Correct Answer: A, B, C, E
Rationale: The correct answers are A, B, C, and E. Reporting communicable diseases like SARS is crucial for planning and evaluating control and prevention strategies. It helps in determining public health priorities by identifying trends and areas that require attention. Reporting ensures proper medical treatment for the affected individuals and their contacts, preventing further spread. Additionally, monitoring for common-source outbreaks allows for timely intervention to limit the spread of the disease. Choices D, F, and G are incorrect as they do not directly relate to the rationale for reporting communicable diseases in this context.