The nurse is caring for a client who was admitted to the medical unit. The healthcare provider states that the client's Romberg test was positive
As the nurse plans to meet the client's elimination needs, the nurse would implement which of the following interventions? 1. Allow the client to walk independently.
2. Obtain an order for a catheter.
3. Limit fluid intake.
4. Obtain a bedside commode.
4
Rationale 1: A positive Romberg sign indicates problems with the vestibular apparatus that controls balance. This client might experience difficult ambulating and has a higher risk of falling. The nurse must help the client eliminate safely.
Rationale 2: Catheter insertion is invasive and increases the client's risk of developing a urinary tract infection.
Rationale 3: Restricting fluid intake is not indicated in this situation.
Rationale 4: A positive Romberg sign indicates problems with the vestibular apparatus that controls balance. This client might experience difficult ambulating and has a higher risk of falling. The nurse must help the client eliminate safely. Obtaining a bedside commode for the client will help prevent the client from falling while attempting to ambulate independently to and from the bathroom.
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