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?

Choice A reason: Breathing difficulty is the highest priority, as it affects oxygenation, a life-threatening issue. Pain is next, impacting comfort and recovery, followed by sleep, which supports healing. This follows the ABC (Airway, Breathing, Circulation) prioritization, making it the correct order for addressing the patient’s issues.

Choice B reason: Prioritizing sleep over pain after breathing is incorrect; pain is more urgent, as it distresses and affects recovery, while sleep is secondary. Breathing remains first, but pain precedes sleep, so this is incorrect for prioritization.

Choice C reason: Sleep as the first priority ignores breathing, a critical life-threatening issue. Breathing and pain are more urgent, with sleep supporting long-term recovery, so this is incorrect for acute care prioritization principles.

Choice D reason: Placing sleep first and breathing last disregards life-threatening breathing issues. Breathing, then pain, then sleep align with ABC priorities, ensuring patient patient safety, so this is incorrect for the nurse’s approach.

Choice A reason: Homan sign tests for deep vein thrombosis, not balance. Swaying with eyes closed indicates a positive Romberg sign, so this is incorrect for the documented finding.

Choice B reason: Lack of coordination is vague and not specific to the Romberg test, which assesses proprioception. Positive Romberg sign describes the sway, so this is incorrect for documentation.

Choice C reason: A positive Romberg sign is documented when a patient sways or loses balance with eyes closed, indicating proprioceptive or cerebellar issues. This is the correct term for the finding.

Choice D reason: Ataxia describes general movement, not the specific Romberg test outcome. Swaying in this context is a Romberg sign, so this is incorrect for the nurse’s documentation.