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
Explanation
Choice A reason:
Hypertension is a common manifestation of increased intracranial pressure (ICP). As ICP rises, the body attempts to maintain cerebral perfusion by increasing blood pressure. This compensatory mechanism helps ensure that the brain continues to receive adequate blood flow despite the elevated pressure.
Choice B reason:
Tinnitus, or ringing in the ears, is not a typical manifestation of increased ICP. While it can be a symptom of various conditions, it is not specifically associated with elevated intracranial pressure.
Choice C reason:
Hypotension, or low blood pressure, is not a manifestation of increased ICP. In fact, the body typically responds to increased ICP with hypertension to maintain cerebral perfusion. Hypotension would be concerning for other reasons but is not indicative of elevated intracranial pressure.
Choice D reason:
Tachycardia, or an increased heart rate, is not a primary manifestation of increased ICP. While changes in heart rate can occur with severe neurological conditions, hypertension is a more direct indicator of elevated intracranial pressure.
Correct Answer is B
Explanation
Choice a reason:
A negative-pressure isolation room is designed to prevent the spread of airborne infectious diseases by ensuring that air flows into the room but not out of it. This type of room is typically used for patients with diseases such as tuberculosis, measles, or COVID-19, which are spread through airborne particles. Scabies, however, is spread through direct skin-to-skin contact or by sharing personal items like bedding or clothing. Therefore, a negative-pressure isolation room is not necessary for a patient with scabies, as the primary mode of transmission is not airborne.
Choice b reason:
A private room is the most appropriate setting for a client with scabies. Scabies is highly contagious and can spread through direct skin-to-skin contact or by sharing personal items. Placing the client in a private room helps to prevent the spread of the mites to other patients and staff. In a private room, the client can be isolated effectively, and healthcare workers can implement contact precautions, such as wearing gloves and gowns, to minimize the risk of transmission. This approach ensures that the client receives appropriate care while protecting others from potential exposure.
Choice c reason:
A semi-private room with a client who has pediculosis capitis (head lice) is not suitable for a client with scabies. Although both conditions involve infestations, they are caused by different parasites and have different modes of transmission. Pediculosis capitis is spread through direct contact with infested hair or personal items, while scabies is spread through prolonged skin-to-skin contact. Placing a client with scabies in a semi-private room with another infested patient increases the risk of cross-contamination and further spread of both conditions. Therefore, this option is not recommended.
Choice d reason:
A positive-pressure isolation room is designed to protect immunocompromised patients from airborne pathogens by ensuring that air flows out of the room but not into it. This type of room is used for patients who need to be protected from infections, such as those undergoing chemotherapy or with severe immune deficiencies. Since scabies is not an airborne disease and does not pose a risk to immunocompromised patients in this manner, a positive-pressure isolation room is not appropriate for a client with scabies. The primary concern with scabies is preventing direct contact transmission, which is best managed in a private room.