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
Explanation
Choice A reason:
Closing the school for 6 weeks is an extreme measure that is not typically warranted for managing influenza outbreaks. Public health guidelines usually recommend temporary closures or other measures to control the spread of infection, but a 6-week closure is excessive and disruptive.
Choice B reason:
Education regarding respiratory and hand hygiene is an appropriate and effective action to help control the spread of influenza. Teaching students and staff about proper handwashing techniques, respiratory etiquette, and other preventive measures can significantly reduce the transmission of the virus. This approach empowers the school community to take proactive steps in preventing further infections.
Choice C reason:
Discipline in the school setting for improper handwashing is not an appropriate response. While it is important to encourage proper hygiene practices, using disciplinary measures can create a negative environment and may not effectively promote behavior change. Education and positive reinforcement are more effective strategies.
Choice D reason:
Running a mandatory flu clinic can be beneficial, but it is not the most immediate or appropriate action in response to an outbreak. Flu clinics are typically part of broader vaccination efforts and may not address the immediate need to control the current outbreak. Education on hygiene practices is a more immediate and practical response.
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.