neuro prepU
The nurse is preparing to perform the Romberg test on an adult male client. The nurse should instruct the client to squat down as far as he is able to do so. keep his eyes open while he bends at the knees. stand erect with arms at the sides and feet together. touch the tip of his nose with his finger.
stand erect with arms at the sides and feet together. Explanation: Perform the Romberg test. Ask the client to stand erect with arms at side and feet together. Note any unsteadiness or swaying. Then with the client in the same body position, ask the client to close the eyes for 20 seconds. Again note any imbalance or swaying.
The nurse performs a neurological assessment and determines the Glasgow Coma Scale (GCS) score is 15. What is the nurse's best action? Notify the healthcare provider. Re-assess in 15 minutes. Document the findings. Ask the client to open eyes on command.
Document the findings. A GCS score of 15 is the maximum score indicating the client's neurological status is normal. Therefore, the nurse should document the findings. This information makes all the remaining options incorrect.
The nurse is performing the Romberg test as part of a client's focused neurological assessment. What finding would constitute a positive Romberg test? The client moves her feet apart to prevent herself from falling. The client is unable to consistently touch her finger to her nose while her eyes are close. The client experiences pain during neck flexion and extension. The client experiences pain when clenching her teeth.
The client moves her feet apart to prevent herself from falling. The Romberg test assesses balance; swaying or repositioning during the test constitutes positive findings. The Romberg test does not address pain during neck flexion or teeth clenching. It does not require the client to touch the nose with a finger.
The nurse is planning to assess a client for graphesthesia. How will the nurse perform this phase of assessment? The client will close the eyes and identify what number the nurse writes in the palm of the client's hand with a blunt-ended object. The client is asked to identify the number of points felt when the nurse touches the client with the ends of two applicators at the same time. The nurse will simultaneously touch the client in the same area on both sides of the body, and the client will identify where the touch occurred. Have the client close the eyes. The nurse will then gently touch the client, and the client will identify where the touch occurred.
The client will close the eyes and identify what number the nurse writes in the palm of the client's hand with a blunt-ended object. Graphesthesia is the ability to identify what is being drawn on the client's body when the client's eyes are closed. Two-point discrimination is tested by having the client identify the number of points felts when touched with the ends of two applicators at the same time. Extinction is tested by simultaneously touching the client in the same area on both sides of the body at the same points and having the client identify the area touched. Point localization is tested by briefly touching the client and then asking the client to identify the points touched.
