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 ["A","B","C","E"]
Explanation
Choice A reason:
Identification of resources to meet anticipated needs is a critical component of disaster planning. Nurses play a key role in identifying the resources required for effective disaster response, including medical supplies, personnel, and equipment. This ensures that the hospital is prepared to meet the needs of patients during a disaster.
Choice B reason:
Participation in comprehensive annual drills is essential for disaster preparedness. Nurses are involved in these drills to practice and refine their response skills, ensuring they are ready to act effectively in a real disaster. Drills help identify gaps in the disaster plan and provide opportunities for improvement.
Choice C reason:
Internal and external communications are vital during a disaster. Nurses are involved in establishing and maintaining communication channels within the hospital and with external agencies. Effective communication ensures coordination and timely response, which are crucial for managing a disaster situation.
Choice D reason:
Performing duties outside the typical job description may occur during a disaster, but it is not a primary component of the disaster plan. The focus is on ensuring that all staff are prepared to perform their roles effectively. While flexibility is important, the disaster plan should primarily outline specific roles and responsibilities.
Choice E reason:
Development of a decontamination plan is an important aspect of disaster preparedness, especially in scenarios involving hazardous materials. Nurses contribute to creating and implementing decontamination protocols to protect patients and staff from exposure to harmful substances.
Correct Answer is B
Explanation
Choice A reason:
A gradual onset of headache is more characteristic of other types of headaches or conditions, such as tension headaches or migraines. Hemorrhagic strokes, particularly those caused by a ruptured cerebral aneurysm, typically present with a sudden and severe headache, often described as the “worst headache of my life.” This sudden onset is due to the rapid accumulation of blood in the brain, which increases intracranial pressure and causes immediate symptoms.
Choice B reason:
Changes in consciousness are a common manifestation of a hemorrhagic stroke. The sudden bleeding into the brain can disrupt normal brain function, leading to symptoms such as confusion, lethargy, or loss of consciousness. These changes occur rapidly and are a key indicator of a serious neurological event. The nurse should be vigilant for any alterations in the client’s level of consciousness, as this can signify worsening of the condition and the need for immediate medical intervention.
Choice C reason:
A gradual onset of several hours is not typical for hemorrhagic strokes. These strokes usually present with sudden and severe symptoms due to the abrupt rupture of a blood vessel in the brain. The rapid increase in intracranial pressure from the bleeding causes immediate and severe symptoms, rather than a slow progression over hours.
Choice D reason:
A history of neurologic deficits lasting less than 1 hour is more indicative of a transient ischemic attack (TIA), also known as a mini-stroke. TIAs are temporary and resolve within a short period without causing permanent damage. In contrast, a hemorrhagic stroke caused by a ruptured cerebral aneurysm results in immediate and severe symptoms that do not resolve quickly and require urgent medical attention.