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","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.
Correct Answer is ["A","B","C","E"]
Explanation
Choice A reason:
Monitoring vital signs of postoperative clients is a task that can be safely delegated to an experienced LPN. LPNs are trained to monitor and report vital signs, which is a routine and essential part of postoperative care. This task does not require the advanced assessment skills of an RN, making it appropriate for delegation.
Choice B reason:
Administering routine medications to stable clients is within the scope of practice for LPNs. They are trained to administer medications and monitor clients for adverse reactions. As long as the clients are stable and the medications are routine, this task can be delegated to an LPN.
Choice C reason:
Performing wound care on a client with a Stage III pressure ulcer is a task that an experienced LPN can perform. LPNs are skilled in wound care and can manage complex dressings and treatments under the supervision of an RN. This delegation allows the RN to focus on more complex tasks that require their advanced skills.
Choice D reason:
Developing a teaching plan for a client newly diagnosed with Type II Diabetes is a task that should not be delegated to an LPN. This task requires comprehensive knowledge of diabetes management, patient education, and individualized care planning, which are within the RN’s scope of practice. The RN should develop the teaching plan and may involve the LPN in reinforcing the education.
Choice E reason:
Providing oral care to an unconscious client is a task that can be delegated to an experienced LPN. Oral care is essential for preventing infections and maintaining hygiene, and LPNs are trained to perform this care safely and effectively.