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A nurse is completing the Romberg's test on a patient. Which is the correct technique for conducting this?

Instruct the client to lie on his back and slowly slide his heel down the shin of the opposite leg, from the knee to the ankle.

Instruct the client to walk across the room on his heels and to return walking on his toes.

Have the client stand with feet together, arms at the sides. Begin with eyes open then with eyes closed. Try to maintain position for 20 seconds.

Ask the client to touch the thumb of one hand to each finger on that same hand and then repeat using the other hand.

Answer and Explanation

The Correct Answer is C

Choice A reason: Heel-to-shin tests cerebellar coordination, not balance like Romberg’s. It assesses motor precision, not proprioception or vestibular function, which Romberg’s targets by checking sway with eyes closed, making this technique irrelevant to the intended assessment here.

Choice B reason: Walking on heels and toes evaluates motor strength and coordination, not stationary balance. Romberg’s tests proprioceptive stability, not gait, missing the core focus on vestibular and sensory integration critical to this neurological balance assessment fully.

Choice C reason: Romberg’s test assesses balance by having the client stand, feet together, eyes open then closed for 20 seconds. Sway with eyes closed indicates proprioceptive or vestibular issues, making this the precise, standard technique for this evaluation accurately.

Choice D reason: Finger-to-thumb tests fine motor skills and coordination, not balance. Romberg’s focuses on postural stability via sensory input, not hand dexterity, rendering this action unrelated to assessing the client’s equilibrium as intended in this context completely.

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Correct Answer is C

Explanation

Choice A reason: The base of the skull houses occipital nodes, not submental ones, which drain the lower face. Palpating here misses the submental region, irrelevant to sinus or throat infections, misaligning with lymphatic drainage patterns in this case.

Choice B reason: The angle of the jaw targets submandibular nodes, not submental, which sit midline under the chin. This area drains the jaw and mouth but not specifically the submental zone tied to the client’s symptoms directly.

Choice C reason: Behind the chin tip is the submental node location, draining the lower lip, tongue, and anterior mouth. With sinus and throat infection, this spot is key for detecting lymphadenopathy linked to the client’s fever and elevated WBC.

Choice D reason: Behind the ears assesses postauricular nodes, unrelated to submental drainage of the chin and mouth. This misses the infection’s likely lymphatic response, focusing on a region not typically involved in sinus or throat pathology here.

A. Assess for further signs of infection B. Document this normal finding C. Set up a teaching session regarding ear hygiene D. Make a note on the chart so the clinician can order ear drops

Correct Answer is B

Explanation

Choice A reason: Small/moderate brown cerumen is normal, not a sign of infection, which shows pus or redness. Assessing further wastes effort, as cerumen protects the canal, and no symptoms like pain or hearing loss suggest pathology here requiring investigation.

Choice B reason: Documenting small/moderate brown cerumen as normal is correct, as it’s a protective earwax variant. Absent symptoms, this finding needs no intervention, aligning with standard practice to record typical ear assessments without escalating care unnecessarily in this case.

Choice C reason: Teaching hygiene isn’t needed for normal cerumen levels, which self-regulate. Excessive cleaning risks impaction or injury, and with no blockage or symptoms, this action overcomplicates a routine finding better left to natural ear processes here.

Choice D reason: Noting for ear drops assumes intervention for a non-issue. Normal brown cerumen doesn’t require softening or removal unless symptomatic, making this step premature and unnecessary, diverging from evidence-based care for typical ear findings fully.

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A nurse is completing the Romberg's test on a patient. Which is the correct technique for conducting this?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

The nurse has completed the assessment of the client's ears. A small/moderate amount of brown cerumen was found in both ears. Which action by the nurse is warranted?

Correct Answer is B

Explanation

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