The nurse is caring for a client who was admitted to the medical unit. The healthcare provider states that the client's Romberg test is positive. In order to meet this client's elimination needs, which intervention will the nurse implement?
Obtain an order for a catheter
Allow the client to walk independently
Obtain a bedside commode
Limit fluid intake
The Correct Answer is C
A) Obtain an order for a catheter: While catheterization can help manage elimination needs, it is generally considered a more invasive approach and is not the first line of action unless absolutely necessary. The goal should be to maintain the client’s dignity and encourage as much independence as safely possible.
B) Allow the client to walk independently: Given that the Romberg test is positive, indicating potential balance issues, allowing the client to walk independently could increase the risk of falls and injury. Safety is a primary concern in this situation.
C) Obtain a bedside commode: This intervention is appropriate as it provides a safe and accessible option for the client to meet their elimination needs without the need to navigate to a bathroom, which may be challenging given their balance issues. A bedside commode allows for easier access while minimizing the risk of falls.
D) Limit fluid intake: Limiting fluid intake is not a safe or effective way to address elimination needs and could lead to dehydration and other complications. Encouraging appropriate fluid intake is important for overall health, provided the client can manage elimination safely.
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Correct Answer is D
Explanation
A) Friction rubs: These sounds are typically heard over the liver or spleen and indicate inflammation of the peritoneal surface. They are not standard findings during routine abdominal auscultation and are more specific to certain conditions.
B) Crepitus: This term refers to a crackling or popping sound often associated with joint movement or subcutaneous air and is not related to abdominal auscultation. It is not something a nurse would expect to hear when listening to bowel sounds.
C) Bruits: These are abnormal sounds that indicate turbulent blood flow, typically assessed over blood vessels rather than the abdomen itself. While they can be detected in some abdominal conditions, they are not the primary sounds expected during routine abdominal auscultation.
D) High pitched gurgling: This is characteristic of normal bowel sounds and indicates active peristalsis. High-pitched, gurgling sounds are a common finding during abdominal auscultation, reflecting the movement of gas and fluids in the intestines. This is what the nurse would expect to hear when assessing the abdomen.
Correct Answer is A
Explanation
A) VII: The facial nerve (cranial nerve VII) is responsible for controlling the muscles of facial expression. By assessing facial symmetry and movement, the nurse evaluates the integrity and function of this nerve, which is crucial for activities such as smiling, frowning, and raising eyebrows.
B) V: The trigeminal nerve (cranial nerve V) is primarily responsible for sensation in the face and motor functions such as chewing. While it plays a role in facial movement, it does not specifically assess facial expressions.
C) III: The oculomotor nerve (cranial nerve III) controls eye movement and pupil constriction. It does not directly influence facial expressions, so it is not the nerve being assessed in this context.
D) VI: The abducens nerve (cranial nerve VI) is responsible for lateral eye movement. It is unrelated to facial expression or symmetry and is not the focus of this assessment.