Sandy is studying for her sensory skills examination. She needs help with her review. Discuss and explain the Romberg test
a. Is it valid for testing balance?
b. Why or why not?
Students' answers should include the following:
a. Test for balance and a person's ability to sustain balance
b. Additional testing is needed to confirm results.
Central nervous system lesions cause similar results; therefore, it isn't exclusive on its own.
Not effective for clients who are unsteady on their feet
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The nurse is attempting to assess a client who appears agitated. The client believes the nurse is trying to hurt him and is not cooperating with the nurse. What actions by the nurse are indicated? Standard Text: Select all that apply
1. Advise the client that the healthcare provider will be contacted unless the client complies. 2. Restrain the client using leather restraints. 3. Speak to the client in a calm voice. 4. Explain actions to the client as they are done. 5. Medicate the client.
When taking the vital signs of a client who had a total hip replacement on the left side 2 days ago, the nurse finds that the client's left leg is cool and capillary refill in the left foot is slug-gish. What is the nurse's best first action?
A. Elevate the left leg and apply antiembolic stockings. B. Assess the circulatory status of the right leg. C. Notify the emergency team. D. Document the finding as the only action.
Fineout-Overholt and Johnston recommended a 5-component scheme for formulating evidence-based practice questions, using the acronym PICOT as a guide. Which two components are not always needed in this model?
A) P and C B) I and O C) C and T D) P and O
A nurse is frustrated about what she feels is a lack of staff on her shift. When one of the patients fell and broke his hip, she documented the incident in the patient's chart
Which of the following is the best way that she should document what happened? A. "Fell while going to the bathroom. Physician notified." B. "Nobody available to answer call bell; patient got up on own and fell." C. "Patient fell due to unsafe staffing levels on unit." D. "Patient waited as long as he could; nobody there to help him and he fell."