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:
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.
Correct Answer is B
Explanation
Choice A reason:
The assistive personnel’s ability to complete the task without assistance is important, but it is encompassed within the broader consideration of their competency and experience. Ensuring that the personnel can perform the task independently is part of assessing their overall capability.
Choice B reason:
The assistive personnel’s level of experience and competency in performing the task is a critical factor in the delegation process. The nurse must ensure that the personnel have the necessary skills and knowledge to perform the task safely and effectively. This consideration aligns with the “right person” aspect of the five rights of delegation, ensuring that the task is delegated to someone who is qualified to perform it.
Choice C reason:
The assistive personnel’s rapport with clients is beneficial for providing compassionate care, but it is not a primary consideration in the delegation process. The focus should be on the personnel’s ability to perform the task competently and safely.
Choice D reason:
The assistive personnel’s availability at the time of the delegation is a logistical consideration, but it does not address the critical aspect of competency. While availability is necessary, it is secondary to ensuring that the personnel are capable of performing the task.