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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale

While method of administration is crucial, controlled substance schedule and identification are not universally required on every prescription. The core components for safe and effective medication administration are paramount for all prescriptions.

Choice B rationale

This choice omits the method of administration, which is vital for safe and effective drug delivery. Without this information, there is a risk of administering the medication incorrectly, potentially leading to adverse effects or lack of therapeutic benefit.

Choice C rationale

A complete prescription scientifically requires the drug name for identification, the dose to ensure therapeutic effect and prevent toxicity, the method of administration for correct delivery route, and the prescriber's signature for legal authorization and accountability.

Choice D rationale

Controlled substance schedules are specific to certain medications and identification is not a standard universal requirement on all prescriptions. The core components for general medication administration are the drug name, dose, method, and prescriber signature.

A. The patch should always be placed in the same location. B. The nurse can discard these medications in the trash can. C. These patches can be placed anywhere on the body. D. The nurse should always wear gloves when handling these medications.

Correct Answer is D

Explanation

Choice A rationale

Placing the patch in the same location repeatedly can lead to skin irritation, reduced absorption due to stratum corneum thickening, and localized adverse reactions. Rotation of application sites allows the skin to recover, maintains optimal drug absorption, and prevents cumulative dermal irritation.

Choice B rationale

Transdermal patches often contain significant amounts of medication, including controlled substances or potent drugs. Discarding them in the trash can poses risks of accidental exposure to others, environmental contamination, and diversion. Proper disposal protocols, such as flushing or returning to pharmacy, are crucial.

Choice C rationale

While transdermal patches are designed for systemic absorption, specific sites are recommended to optimize efficacy and minimize adverse effects. Areas with less hair, intact skin, and good circulation are preferred. Improper placement can lead to erratic absorption or local irritation, reducing therapeutic benefit.

Choice D rationale

The nurse should always wear gloves when handling transdermal patches to prevent direct skin contact with the medication. Many transdermal drugs can be absorbed through the nurse's skin, leading to unintended pharmacological effects or sensitization. Gloves provide a crucial barrier against dermal absorption.

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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):

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Naxlex Comprehensive Predictor Exams

The student nurse knows that a prescription requires which of the following information?

Correct Answer is C

Explanation

Which of the following is true regarding transdermal patches?

Correct Answer is D

Explanation

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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):