A 29-year-old woman tells the nurse that she has “excruciating pain” in her back. Which would be an appropriate response by the nurse to the woman’s statement?

Choice A reason: Measuring respirations during pulse assessment can lead to inaccurate counts, as patients may alter their breathing when aware of pulse measurement. Conscious awareness often causes irregular or controlled breathing, which does not reflect the true respiratory rate, making this an unreliable time.

Choice B reason: Auscultation involves listening to lung or heart sounds, which requires patient cooperation and often affects breathing patterns. Patients may consciously modify their respirations during this process, leading to inaccurate respiratory rate measurements, rendering this an unsuitable time for assessment.

Choice C reason: Interviewing involves patient interaction, which can influence breathing due to speech or emotional responses. This conscious activity often results in irregular or controlled breathing patterns, making it an unreliable time to accurately measure the patient’s natural respiratory rate.

Choice D reason: Measuring respirations when the patient is sleeping ensures an undisturbed, natural breathing pattern, as the patient is unaware of the assessment. This allows the nurse to count the respiratory rate accurately, reflecting the true resting state, making it the optimal time.

Choice A reason: Dorsiflexion and toe fanning indicate a Babinski sign, a reflex test, not Romberg’s sign. Romberg’s sign involves balance issues with closed eyes, so this is incorrect for the neurological assessment.

Choice B reason: A positive Romberg’s sign is observed when a patient sways significantly or loses balance when standing with feet together and eyes closed, indicating impaired proprioception or cerebellar function. This is the correct observation for the test.

Choice C reason: Rhythmic eye twitching (nystagmus) is unrelated to Romberg’s test, which assesses balance. Swaying with closed eyes defines a positive Romberg’s, sign, so this is incorrect for the outcome.

Choice D reason: Inability to point fingers to a reference tests coordination, not the Romberg’s test, which focuses on balance with eyes closed. Significant swaying is the correct sign, so this is incorrect.