Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is providing information to a client immediately before his scheduled Romberg test.
Which of the following statements should the nurse make?
A. "You will be standing with your feet 1 foot apart."
The client should stand with their feet together, not 1 foot apart, for the Romberg test.
B. "You will place and hold your hands on your hips."
The client should hold their arms at their sides, not on their hips, for the Romberg test.
C. "I will be standing across the room from you to evaluate your sense of balance."
The nurse should stand close to the client, not across the room, to prevent injury in case of a fall.
D. "I will be checking you once with your eyes open and once with them closed."
The Romberg test involves checking the client's balance with their eyes open and then with their eyes closed.
This question is an excerpt from Nurse Dive's nursing test bank - RN Comprehensive Online Practice 2019 B with NGN Proctored Exam. Take the full exam now
Full Explanation
A is incorrect because the client should stand with their feet together, not 1 foot apart, for the Romberg test.
B is incorrect because the client should hold their arms at their sides, not on their hips, for the Romberg test.
C is incorrect because the nurse should stand close to the client, not across the room, to prevent injury in case of a fall.
D is correct because the Romberg test involves checking the client's balance with their eyes open and then with their eyes closed.
Similar Questions
During a change-of-shift report, a night shift nurse informs the day shift nurse that a newly admitted client was disoriented and combative during the night. Which of the following actions should the day shift nurse take?
A. Keep the client's television on with the volume low
Keep the client's television on with the volume low: This is incorrect because it does not address the client's safety or agitation. The television might also be a source of confusion or stimulation for the client.
B. Insert an indwelling urinary catheter to minimize interaction with the client
Insert an indwelling urinary catheter to minimize interaction with the client: This is incorrect because it is an invasive and unnecessary procedure that increases the risk of infection and trauma. It also violates the client's dignity and autonomy.
C. Consult the provider regarding administering a mild sedative on a schedule
Consult the provider regarding administering a mild sedative on a schedule: This is incorrect because it is not the first action to take. The nurse should first assess the client's condition and identify possible causes of disorientation and combativeness, such as pain, infection, medication side effects, or delirium. Sedatives should be used as a last resort and only with informed consent.
D. Move the client to a room near the nurses' station
Move the client to a room near the nurses' station: This is correct because it allows for close observation and supervision of the client, which can prevent injury and promote safety. It also facilitates frequent interaction and reassurance from the staff, which can reduce anxiety and agitation.
Full Explanation
Move the client to a room near the nurses' station.
- A. Keep the client's television on with the volume low: This is incorrect because it does not address the client's safety or agitation. The television might also be a source of confusion or stimulation for the client.
- B. Insert an indwelling urinary catheter to minimize interaction with the client: This is incorrect because it is an invasive and unnecessary procedure that increases the risk of infection and trauma. It also violates the client's dignity and autonomy.
- C. Consult the provider regarding administering a mild sedative on a schedule: This is incorrect because it is not the first action to take. The nurse should first assess the client's condition and identify possible causes of disorientation and combativeness, such as pain, infection, medication side effects, or delirium. Sedatives should be used as a last resort and only with informed consent.
- D. Move the client to a room near the nurses' station: This is correct because it allows for close observation and supervision of the client, which can prevent injury and promote safety. It also facilitates frequent interaction and reassurance from the staff, which can reduce anxiety and agitation.
A nurse in an emergency department is caring for a client who is unconscious and requires emergency medical procedures. The nurse is unable to locate members of the client's family to obtain consent. Which of the following actions should the nurse take?
A. Contact the facility's ethics committee
This is incorrect because it is not an urgent action and it does not address the client's immediate needs. The ethics committee can be consulted later if there are ethical dilemmas or conflicts regarding the client's care.
B. Obtain consent from the client's employer
This is incorrect because it is not a valid source of consent. The employer has no legal or ethical authority to make decisions for the client, unless they are also a designated surrogate or proxy.
C. Limit care to comfort measures
This is incorrect because it does not meet the standard of care for an emergency situation. The nurse has a duty to provide life-saving interventions for a client who is unconscious and requires emergency medical procedures, unless there is evidence of a valid advance directive that states otherwise.
D. Proceed with provision of medical care
This is correct because it follows the principle of implied consent, which assumes that a reasonable person would consent to emergency treatment if they were able to do so. The nurse should document the circumstances and continue to search for family members or other sources of consent.
Full Explanation
Proceed with provision of medical care.
- A. Contact the facility's ethics committee: This is incorrect because it is not an urgent action and it does not address the client's immediate needs. The ethics committee can be consulted later if there are ethical dilemmas or conflicts regarding the client's care.
- B. Obtain consent from the client's employer: This is incorrect because it is not a valid source of consent. The employer has no legal or ethical authority to make decisions for the client, unless they are also a designated surrogate or proxy.
- C. Limit care to comfort measures: This is incorrect because it does not meet the standard of care for an emergency situation. The nurse has a duty to provide life-saving interventions for a client who is unconscious and requires emergency medical procedures, unless there is evidence of a valid advance directive that states otherwise.
- D. Proceed with provision of medical care: This is correct because it follows the principle of implied consent, which assumes that a reasonable person would consent to emergency treatment if they were able to do so. The nurse should document the circumstances and continue to search for family members or other sources of consent.
A charge nurse is speaking with the partner of a client. The partner states that the client is not receiving adequate care. Which of the following actions should the charge nurse take first to resolve the situation?
A. Evaluate the changes the partner requests
This is incorrect because it is not the first action to take. The charge nurse should first listen to and acknowledge the partner's complaints before evaluating any changes or solutions.
B. Review the client's plan of care
This is incorrect because it is not the first action to take. The charge nurse should first understand what aspects of care are unsatisfactory for the partner and why they feel that way.
C. Analyze other reports of poor care to look for trends
This is incorrect because it is not relevant to this situation. The charge nurse should focus on addressing this specific case of dissatisfaction rather than looking for general patterns or issues.
D. Ask the partner to list specific concerns
This is correct because it shows respect and empathy for the partner and allows for clarification and communication of their expectations and needs. It also helps identify any gaps or misunderstandings in the client's care and facilitates problem-solving and resolution.
Full Explanation
Ask the partner to list specific concerns.
- A. Evaluate the changes the partner requests: This is incorrect because it is not the first action to take. The charge nurse should first listen to and acknowledge the partner's complaints before evaluating any changes or solutions.
- B. Review the client's plan of care: This is incorrect because it is not the first action to take. The charge nurse should first understand what aspects of care are unsatisfactory for the partner and why they feel that way.
- C. Analyze other reports of poor care to look for trends: This is incorrect because it is not relevant to this situation. The charge nurse should focus on addressing this specific case of dissatisfaction rather than looking for general patterns or issues.
- D. Ask the partner to list specific concerns: This is correct because it shows respect and empathy for the partner and allows for clarification and communication of their expectations and needs. It also helps identify any gaps or misunderstandings in the client's care and facilitates problem-solving and resolution.