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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason: ALS is a neurodegenerative disease that affects the motor neurons, which control the voluntary muscles. It does not affect the cognitive or mental functions, such as memory, reasoning, or emotions. Therefore, the person with ALS will be aware of their condition and their surroundings, even when they lose their ability to move, speak, or breathe.

Choice B reason: ALS affects the muscles of the mouth, throat, and chest, which are involved in swallowing. As the disease progresses, the person with ALS will have difficulty swallowing food, liquids, and saliva. This can lead to malnutrition, dehydration, choking, and aspiration pneumonia.

Choice C reason: ALS does not directly cause seizures, which are abnormal electrical activity in the brain. However, some medications used to treat the symptoms of ALS, such as muscle relaxants, may increase the risk of seizures. Therefore, the person with ALS should be monitored for any signs of seizures, such as loss of consciousness, convulsions, or confusion.

Choice D reason: ALS affects the muscles of the diaphragm and the intercostal muscles, which are involved in breathing. As the disease progresses, the person with ALS will have difficulty breathing, especially at night or when lying down. This can lead to respiratory failure, which is the most common cause of death in ALS. Therefore, the person with ALS may need mechanical ventilation or noninvasive positive pressure ventilation to support their breathing.

A. Patient sways from side-to-side when standing with feet close together. B. Patient's pupils do not respond equally to direct light from a flashlight. C. Patient takes two attempts to touch their nose while their eyes are closed. D. Patient complains of mild dizziness.

Correct Answer is A

Explanation

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.

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The nurse completes a Romberg's test on a patient with neurologic changes. The nurse will notify the provider if they observe which response?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

The nurse completes a Romberg's test on a patient with neurologic changes. The nurse would notify the provider if they observe which response?

Correct Answer is A

Explanation

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