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 C
Explanation
Choice A reason:
Assisting the client with active range of motion exercises is important for preventing complications such as contractures and maintaining mobility. However, it is not the priority intervention in the acute phase of a hemorrhagic stroke. The primary focus should be on stabilizing the client and monitoring their condition closely.
Choice B reason:
Maintaining strict bed rest to minimize cerebral blood flow is not appropriate for managing a hemorrhagic stroke. While bed rest may be necessary to prevent further injury, the priority is to monitor the client’s neurological status and vital signs to detect any changes that may indicate worsening of the condition.
Choice C reason:
Monitoring vital signs and neurological status frequently is the priority intervention for a client who has experienced a hemorrhagic stroke. Close monitoring allows the nurse to detect any changes in the client’s condition promptly and take appropriate action. This is crucial for preventing complications and ensuring timely intervention if the client’s condition deteriorates.
Choice D reason:
Administering anticoagulant medications is contraindicated in hemorrhagic stroke because they can exacerbate bleeding. Anticoagulants are used in ischemic stroke to prevent clot formation, but in hemorrhagic stroke, the focus is on controlling bleeding and stabilizing the client.
Correct Answer is B
Explanation
Choice A reason:
Decreasing bright lights can help alleviate discomfort for the client, especially if they are experiencing photophobia, which is common in meningitis. However, this action does not address the immediate need to prevent the spread of infection. While it is a supportive measure, it is not the first priority in managing a client with suspected meningitis.
Choice B reason:
Implementing droplet precautions is the first priority when a client presents with symptoms suggestive of meningitis, such as a severe headache, stiff neck, and positive Kernig’s and Brudzinski’s signs. Meningitis can be caused by bacterial infections that are highly contagious and spread through respiratory droplets. Initiating droplet precautions helps prevent the transmission of the infection to other clients and healthcare workers, making it the most critical initial action.
Choice C reason:
Initiating IV access is important for administering medications and fluids, but it is not the first priority. Ensuring the safety of others by implementing droplet precautions takes precedence. Once precautions are in place, the nurse can proceed with establishing IV access to facilitate further treatment.
Choice D reason:
Administering antibiotics is crucial in the treatment of bacterial meningitis, but it should be done after droplet precautions are in place to prevent the spread of infection. Prompt antibiotic therapy is essential, but the initial step must focus on infection control measures to protect others from exposure.