When the nurse asks a 68-year-old patient to stand with feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart.
The nurse would document this finding as a(n):
Positive Romberg sign.
Negative Homans' sign.
Lack of coordination.
Ataxia.
The Correct Answer is A
Choice A rationale
A positive Romberg sign is indicated when a patient, asked to stand with feet together and arms at their side with eyes closed, sways significantly or loses balance. This suggests a deficit in proprioception, which is the sense of one's body position in space, as visual input cannot compensate for the impaired proprioceptive feedback to maintain equilibrium.
Choice B rationale
Homans' sign is a clinical indicator for deep vein thrombosis (DVT), assessed by dorsiflexing the foot and observing for calf pain. A negative Homans' sign means no pain is present, and it is unrelated to balance or coordination assessment.
Choice C rationale
Lack of coordination is a general term that could encompass various motor deficits, but "ataxia" is a more specific neurological term for impaired coordination. While swaying and moving feet apart demonstrate a lack of coordination, documenting it as a positive Romberg sign provides a more precise and diagnostically relevant finding in this specific context.
Choice D rationale
Ataxia refers to impaired coordination of voluntary movements, often appearing as clumsiness, inaccuracy, or instability. While the patient's actions exhibit ataxia, the specific maneuver performed (standing with eyes closed) and the resulting sway are characteristic of a positive Romberg sign, which points to a proprioceptive or vestibular deficit.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The Sims position, also known as left lateral position with the right knee flexed, is ideal for rectal suppository administration. This position allows for optimal visualization and access to the anus, while gravity aids in the retention of the suppository by minimizing premature expulsion.
Choice B rationale
The dorsal recumbent position, where the patient lies on their back with knees flexed and feet flat on the bed, is not optimal for rectal suppository administration. This position makes rectal access difficult and does not utilize gravity to aid in suppository retention, potentially leading to discomfort.
Choice C rationale
The prone position, where the patient lies on their stomach, is not suitable for rectal suppository administration. This position severely limits access to the rectal area, making insertion difficult and uncomfortable for both the patient and the nurse.
Choice D rationale
The supine position, where the patient lies flat on their back, is not ideal for rectal suppository administration. Similar to dorsal recumbent, this position makes adequate visualization and comfortable access to the anus challenging, potentially increasing patient discomfort and insertion difficulty.
Correct Answer is C
Explanation
Choice A rationale
The clavicle is a superficial bone forming part of the shoulder girdle and does not serve as a primary site for eliciting deep tendon reflexes. Deep tendon reflexes involve muscle stretch and nerve innervation.
Choice B rationale
The scapula is a large, triangular bone located on the posterior aspect of the rib cage and is not an anatomical landmark used for assessing deep tendon reflexes. Reflexes are elicited from tendons connected to muscles.
Choice C rationale
The patella, or kneecap, is the anatomical landmark where the patellar tendon connects to the quadriceps muscle. Tapping this tendon elicits the patellar reflex, a commonly assessed deep tendon reflex indicating spinal nerve integrity.
Choice D rationale
The sternum, or breastbone, is a flat bone located in the center of the chest and is not associated with the elicitation of deep tendon reflexes. Deep tendon reflexes are assessed at specific musculotendinous junctions.
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