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:
Administering thrombolytics is not the first action the nurse should take. Thrombolytics are used to treat ischemic strokes, but their administration requires a thorough assessment and confirmation of the diagnosis through imaging studies. Immediate action is needed to ensure the client’s safety and initiate the stroke protocol.
Choice B reason:
Calling for help is the first action the nurse should take. The client is exhibiting signs of a possible stroke, and immediate medical intervention is required. Calling for help ensures that the stroke team or emergency response team is activated promptly to provide the necessary care.
Choice C reason:
Providing the client with water to test the gag reflex is not appropriate in this situation. The client may have difficulty swallowing, and giving water could lead to aspiration. The priority is to ensure the client’s safety and initiate the stroke protocol.
Choice D reason:
Performing carotid massage is not indicated for a client with new right-sided weakness and slurred speech. Carotid massage is used to manage certain types of arrhythmias, but it is not appropriate for suspected stroke. The focus should be on immediate assessment and intervention.
Correct Answer is D
Explanation
Choice A reason:
Encouraging the client to use ice therapy to alleviate muscle stiffness is not the best approach for managing multiple sclerosis (MS). While ice therapy can provide temporary relief for muscle stiffness, it does not address the need to increase venous return, prevent stiffness, or maintain muscle strength and endurance. Gentle stretching exercises are more effective for these goals.
Choice B reason:
Administering interferon is a common treatment for MS to help reduce the frequency and severity of relapses. However, it does not directly address the need to increase venous return, prevent stiffness, or maintain muscle strength and endurance. Exercise and physical therapy are more appropriate for these specific goals.
Choice C reason:
Administering corticosteroids is used to manage acute exacerbations of MS by reducing inflammation. While corticosteroids can help manage symptoms during a flare-up, they do not directly contribute to increasing venous return, preventing stiffness, or maintaining muscle strength and endurance. Regular exercise is more effective for these purposes.
Choice D reason:
Encouraging the client to perform gentle stretching exercises daily is the most appropriate action. Stretching exercises help increase venous return, prevent stiffness, and maintain muscle strength and endurance. Regular physical activity is essential for managing MS symptoms and improving overall function and quality of life.