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","E"]
Explanation
Choice A reason:
“I may experience urinary incontinence.” This statement is correct. Urinary incontinence is a common symptom of MS due to the disease’s impact on the nervous system. The client does not need additional teaching regarding this statement.
Choice B reason:
“I should not exercise because this may trigger an exacerbation.” This statement indicates a need for additional teaching. Regular exercise is beneficial for individuals with MS and can help improve strength, mobility, and overall well-being. The nurse should educate the client on safe and appropriate exercise routines.
Choice C reason:
“I need to check the water temperature before I take a bath.” This statement is correct. Clients with MS may have impaired sensation and are at risk for burns if the water is too hot. Checking the water temperature is a necessary precaution.
Choice D reason:
“I may experience visual disturbances.” This statement is correct. Visual disturbances, such as blurred vision or double vision, are common symptoms of MS. The client does not need additional teaching regarding this statement.
Choice E reason:
“I should alternate the eye patch every other day to help with the double vision.” This statement indicates a need for additional teaching. While using an eye patch can help manage double vision, it should be alternated more frequently, typically every few hours, to prevent strain on the covered eye.
Correct Answer is B
Explanation
Choice A reason:
Chewing the tablet before swallowing is not the correct method of administration for Sumatriptan (Imitrex) tablets. These tablets are designed to be swallowed whole. Chewing them could affect the medication’s efficacy and absorption.
Choice B reason:
“If you experience chest pain, call your physician immediately.” This instruction is crucial because Sumatriptan can cause serious cardiovascular side effects, including chest pain, which may indicate a heart attack or other serious condition. Clients need to be aware of this potential side effect and seek immediate medical attention if it occurs.
Choice C reason:
Taking Sumatriptan daily to prevent headaches is incorrect. Sumatriptan is used to treat acute migraine attacks and is not intended for daily use as a preventive medication. Using it daily could lead to medication overuse headaches and other adverse effects.
Choice D reason:
“Repeat dose in 1 hour for unrelieved headache” is partially correct but incomplete. The correct instruction is to repeat the dose after 2 hours if the headache is not relieved, up to a maximum of two doses in 24 hours. Clients should follow the specific dosing instructions provided by their healthcare provider.