A client demonstrates a positive Romberg's sign with eyes closed, but not with eyes open, during the course of the neurologic examination. What conclusion can the nurse make from this observation?
A. The client has difficulty with proprioception.
B. The client has a peripheral motor disorder.
C. The client has a cerebellar lesion.
D. The client has pronator drift.
A
The client who sways with eyes closed (positive Romberg's sign) but not with eyes open most likely has a disorder of proprioception and uses vision to compensate for it.
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The nurse accidentally administers the client's medication to the wrong client. Place the nursing actions in the order they should be performed
Click on the down arrow for each response in the right column and select the correct choice from the list. Response 1. Notify the health care provider and/or charge nurse. Response 2. Document the medication error and complete an incident or event form. Response 3. Administer the medications to the proper client. Response 4. Assess the client receiving the wrong medications. Response 5. Monitor the client who received the wrong medications frequently for untoward effects of the drugs.
A patient with multiple sclerosis is admitted to the unit for an acute exacerbation and is given interferon beta-1a (Avonex). What questions related to adverse effects should the nurse include in the physical assessment?
a. "Are you experiencing any gastrointestinal upset or diarrhea?" b. "Do you have a headache, chills, or muscle aches?" c. "Are you having any swelling in your legs or shortness of breath?" d. "Do you have or have you experienced any ringing in your ears?"
Which is the best indication of learning?
a. Always using information appropriately b. Acquiring new knowledge that results in a persistent change of behavior c. Consistently making good grades on tests taken during school or college d. Identifying important health promotion information to teach patients and families