The nurse is performing the Romberg test on a client during a neurological assessment. Which of the following best describes the rationale for conducting the Romberg test?
To measure respiratory rate and depth.
To evaluate coordination and fine motor skills.
To test for proprioception and vestibular function.
To assess cranial nerve function related to facial expression.
The Correct Answer is C
Choice A reason:
The Romberg test is not used to measure respiratory rate and depth. Respiratory assessments involve observing breathing patterns, rate, and depth, which are unrelated to the Romberg test.
Choice B reason:
While the Romberg test can provide some information about coordination, its primary purpose is not to evaluate fine motor skills. Fine motor skills are typically assessed through tasks that involve precise hand and finger movements.
Choice C reason:
The Romberg test is used to test for proprioception and vestibular function. It assesses the client’s ability to maintain balance with their eyes closed, which helps identify issues with proprioception (the sense of body position) and vestibular function (the inner ear’s role in balance).
Choice D reason:
The Romberg test does not assess cranial nerve function related to facial expression. Cranial nerve assessments involve specific tests for each nerve, such as asking the client to smile or raise their eyebrows to evaluate facial nerve function.
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Correct Answer is B
Explanation
Choice A reason:
Recommending high-impact, vigorous exercises is not appropriate for clients with MS. These exercises can increase the risk of injury and exacerbate symptoms. Instead, low-impact exercises such as swimming, yoga, and stretching are more suitable for improving muscle strength and overall fitness without causing undue stress on the body.
Choice B reason:
Teaching the client stress management techniques such as deep breathing and meditation is an important intervention for managing MS. Stress can exacerbate MS symptoms, so learning effective stress management strategies can help the client maintain better control over their condition and improve their quality of life.
Choice C reason:
Advising the client to avoid social interactions to minimize stress is not a healthy recommendation. Social support is crucial for mental and emotional well-being. Instead of avoiding social interactions, the client should be encouraged to engage in supportive and positive social activities that do not cause stress.
Choice D reason:
Encouraging the client to void every hour is not a standard intervention for MS unless the client has specific bladder control issues. Bladder training and scheduled voiding may be recommended for clients with urinary symptoms, but this should be tailored to the individual’s needs and not applied universally.
Correct Answer is ["B","C","E"]
Explanation
Choice A reason:
The central nervous system is not a common portal of entry for anthrax. Anthrax primarily enters the body through the skin, respiratory tract, or gastrointestinal tract. While it can affect the central nervous system if it spreads, it is not a primary entry point.
Choice B reason:
The integumentary system, or skin, is a common portal of entry for anthrax. Cutaneous anthrax occurs when Bacillus anthracis spores enter the body through a cut or abrasion on the skin. This form of anthrax is characterized by a localized infection that can develop into a painless ulcer with a black center.
Choice C reason:
The respiratory system is another primary portal of entry for anthrax. Inhalation anthrax occurs when spores are inhaled into the lungs. This form of anthrax is particularly dangerous and can lead to severe respiratory distress and systemic infection if not treated promptly.
Choice D reason:
The renal system is not a typical portal of entry for anthrax. While anthrax can affect multiple organ systems if it becomes systemic, it does not enter the body through the kidneys or urinary tract.
Choice E reason:
The gastrointestinal system is a potential portal of entry for anthrax. Gastrointestinal anthrax occurs when spores are ingested, typically through contaminated food or water. This form of anthrax can cause severe gastrointestinal symptoms and systemic infection.