The nurse is performing a neurological assessment on a patient and elicits a positive Romberg’s sign. What observation by the nurse determines this outcome?
Dorsiflexion of the ankle and great toe with fanning of the other toes.
A significant sway when standing feet together, arms at side, and eyes closed.
An involuntary rhythmic twitch of the eyeballs when standing erect.
A patient is unable to return extended fingers to a point of reference.
The Correct Answer is B
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: A social group sharing traits like location or language describes ethnicity or community, not race. Race is primarily based on physical characteristics, not geographic or linguistic ties, making this an incorrect definition.
Choice B reason: The process of acquiring norms and beliefs refers to socialization or culture, not race. Race is defined by physical traits, not learned behaviors or cultural practices, making this an incorrect description.
Choice C reason: Shared attitudes, values, and roles define culture or ethnicity, not race. Race focuses on inherited physical characteristics, like skin color or facial features, not behavioral or social patterns, making this incorrect.
Choice D reason: Race is defined as a group sharing similar physical characteristics, such as skin color, facial features, or other genetic traits. This aligns with biological and anthropological definitions, making it the correct description of race.
Correct Answer is D
Explanation
Choice A reason: Simultaneously palpating both carotid arteries is dangerous, risking reduced cerebral blood flow, especially in cardiovascular patients. Using the bell to listen for bruits is safer, so this is incorrect.
Choice B reason: Deep breaths are for lung auscultation, not carotid, where patients hold breath to reduce noise. The bell detects low-pitched bruits, so instructing deep breaths is incorrect for carotid assessment.
Choice C reason: Compressing the carotid artery risks reducing blood flow or dislodging plaques, which is unsafe. Listening with the bell for bruits is the standard method, so this is incorrect.
Choice D reason: Listening with the bell of the stethoscope detects low-frequency bruits, indicating carotid artery narrowing, which is critical in cardiovascular disease. This is the correct technique for safe assessment.
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