The nurse completes a Romberg's test on a patient with neurologic changes. The nurse will notify the provider if they observe which response?
Patient sways from side-to-side when standing with feet close together.
Patient's pupils do not respond equally to direct light from a flashlight.
Patient takes two attempts to touch their nose while their eyes are closed.
Patient complains of mild dizziness.
The Correct Answer is A
Choice A reason: Swaying during a Romberg test indicates a positive result, suggesting proprioceptive deficits or sensory ataxia.
Choice B reason: Unequal pupil response to light relates to cranial nerve function, not balance assessed by the Romberg test.
Choice C reason: This is incorrect. Patient taking two attempts to touch their nose while their eyes are closed is a mild impairment of coordination, which may be due to neurologic changes or other factors such as fatigue or medication. This is not a significant finding that requires immediate attention.
Choice D reason: This is incorrect. Patient complaining of mild dizziness is a common symptom of neurologic changes or vestibular dysfunction. It is not a serious finding that requires immediate attention. The nurse should monitor the patient and provide comfort measures.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Diabetes mellitus Type 1 is a condition that affects the pancreas and the production of insulin, a hormone that regulates blood sugar levels. It does not directly cause anemia, but it can increase the risk of complications such as infections, ulcers, and nerve damage.
Choice B reason: Peripheral vascular disease is a condition that affects the blood vessels and the circulation of blood to the limbs. It does not directly cause anemia, but it can increase the risk of complications such as clots, wounds, and gangrene.
Choice C reason: Chronic kidney disease is a condition that affects the kidneys and their function of filtering waste and fluids from the blood. It can cause anemia by reducing the production of erythropoietin, a hormone that stimulates the bone marrow to make red blood cells.
Choice D reason: Hypertension is a condition that affects the blood pressure and the force of blood against the artery walls. It does not directly cause anemia, but it can increase the risk of complications such as stroke, heart attack, and kidney damage.
Correct Answer is B
Explanation
Choice A reason: This is incorrect. Numbness of the fingers is not an early sign of a migraine with an aura, but rather a symptom of a sensory aura, which occurs after the visual aura and before the headache. A sensory aura is a tingling or numb sensation that affects one side of the body, usually the face, arm, or hand.
Choice B reason: This is correct. Visual disturbances are an early sign of a migraine with an aura, which precedes the headache by 10 to 60 minutes. A visual aura is a temporary change in vision, such as seeing flashes, zigzags, blind spots, or shimmering shapes.
Choice C reason: This is incorrect. Lethargy is not an early sign of a migraine with an aura, but rather a symptom of the postdrome phase, which occurs after the headache subsides. The postdrome phase is a period of recovery, where the patient may feel tired, weak, or confused.
Choice D reason: This is incorrect. Vertigo is not an early sign of a migraine with an aura, but rather a symptom of a vestibular migraine, which is a type of migraine that affects the balance and hearing. Vertigo is a sensation of spinning or dizziness that may occur with or without a headache.
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