Practice Question
An older adult client is being assessed for motor function and balance. Which test is most appropriate to evaluate both aspects simultaneously?
Answer Choices:
Correct Answer:
Heel-to-toe walking.
Rationale:
🟣 Heel-to-toe walking, or tandem gait, assesses both motor function and balance as the client walks in a straight line placing the heel of one foot directly in front of the toes of the other.
🟣 This task requires leg strength, coordination, cerebellar function, and equilibrium to maintain a narrow base of support.
🟣 Difficulty performing this test may indicate cerebellar dysfunction, weakness, or balance impairment, all of which are important in fall risk assessment.
🟣 Because walking is a functional motor task, this test is highly relevant to everyday activities like ambulating safely.
🟣 Therefore, it is the most appropriate single test listed to evaluate both motor function and balance simultaneously.
Deep tendon reflexes
🟣 Deep tendon reflexes (DTRs) assess spinal cord and peripheral nerve function, giving information about reflex arcs and possible neurologic lesions.
🟣 They do not directly assess balance or functional coordination, only reflex responsiveness (e.g., hypoactive or hyperactive reflexes).
🟣 A client may have normal or abnormal reflexes but still maintain or lose functional balance—it does not give a full picture of motor control in movement.
🟣 Reflex testing is important but is a separate component of the neurologic exam, not a combined motor-and-balance test.
🟣 Therefore, it is not the best choice when the goal is to assess balance and motor performance together.
Finger-to-nose test
🟣 The finger-to-nose test primarily assesses upper extremity coordination and cerebellar function, especially fine motor control.
🟣 It is useful for detecting dysmetria (overshooting or undershooting) and tremors but does not adequately assess standing balance or gait.
🟣 The patient can often perform finger-to-nose while sitting or lying, so equilibrium and postural stability are not fully challenged.
🟣 While it is a good test for coordination, it does not test lower extremity motor control and balance during movement.
🟣 Thus, it is less comprehensive for combined motor + balance assessment compared with heel-to-toe walking.
Romberg test
🟣 The Romberg test is primarily a test of balance and proprioception, not overall motor function.
🟣 In Romberg, the client stands with feet together and eyes closed; a loss of balance suggests issues with proprioception or vestibular function.
🟣 It does not significantly test coordinated stepping or gait, nor does it fully evaluate functional leg motor performance.
🟣 While valuable for balance, it doesn’t combine dynamic movement and motor complexity like heel-to-toe walking.
🟣 Therefore, it is good for balance alone, but not the best choice to assess both motor function and balance simultaneously.
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This question is from Custom Holistic Assessment Exam 3 which contains 50 questions.
More Questions from This Exam
The nurse is assessing an older adult during a head-to-toe exam. Which finding requires immediate intervention?
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Why is it important to assess both balance and coordination in elderly clients?
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When assessing the musculoskeletal system of an aging adult, which finding is unexpected and should be reported?
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The nurse assessing the abdomen of an older adult notes distention and reports of chronic constipation. Which unexpected finding would require immediate provider notification?
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A nurse is conducting a head-to-toe assessment on an older adult. During the musculoskeletal evaluation, which finding requires further investigation?
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI MedSurg
- Answer Choices: 4