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 C
Explanation
Choice A rationale
Facilitation is a verbal technique that encourages the patient to say more by using non-verbal cues, such as nodding, or minimal verbal cues like "Mm-hmm" or "Go on.”. While it promotes communication, the statement "Tell me more about that" is a direct prompt for detailed information, not a subtle encouragement.
Choice B rationale
A direct ask is a specific question that elicits a concise, often one-word or brief, answer, such as "Are you in pain?" or "When did the shortness of breath start?" The nurse's statement, however, invites elaboration and detailed description, going beyond a simple direct response.
Choice C rationale
An open-ended ask is a type of question that encourages a comprehensive and descriptive response from the patient, rather than a simple yes or no answer. By asking "Tell me more about that," the nurse invites the patient to elaborate on their experience of shortness of breath, providing a richer understanding of the symptom.
Choice D rationale
Reflection involves repeating a patient's words or phrases to encourage further expression of their feelings or thoughts. While the nurse acknowledges the patient's mention of "shortness of breath," the statement "Tell me more about that" is an invitation for elaboration, not a direct reflection of the patient's exact words to encourage emotional exploration.
Correct Answer is D
Explanation
Choice A rationale
Delayed documentation increases the risk of medication errors, as details about administration, patient response, and specific timing can be forgotten or inaccurately recalled, compromising patient safety and the accuracy of the medical record.
Choice B rationale
Nurses are legally and professionally obligated to document medications they personally administer. Documentation by a pharmacy technician is inappropriate and violates the principle of direct accountability for medication administration.
Choice C rationale
Only the individual who directly administers the medication should document its administration. This ensures accuracy, accountability, and traceability of the medication process, preventing errors and maintaining legal integrity of the medical record.
Choice D rationale
Immediate documentation after medication administration is a critical safety principle. It accurately reflects the precise time of administration, allowing for timely assessment of patient response, identification of adverse effects, and continuity of care.
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