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 B
Explanation
Choice A rationale
Instilling water to rinse the tube is an important step after medication administration or prior to administering incompatible medications, but it is not the initial and most crucial step before delivering any drug. Placement verification is paramount.
Choice B rationale
Scientifically, confirming tube placement is the absolute first and most critical step before administering any substance, including medication, through an enteral tube. Misplaced tubes can lead to aspiration pneumonia or inefficient drug absorption, posing significant patient safety risks.
Choice C rationale
Laying the client flat may increase the risk of aspiration, especially if the tube is misplaced or if the client has impaired gag reflex. Proper positioning, typically semi-Fowler's, is crucial for safe enteral feeding and medication administration.
Choice D rationale
Assessing bowel sounds is important for evaluating gastrointestinal motility and absorption capacity before initiating or continuing enteral feedings, but it is not the primary immediate safety check required before administering a single dose of medication.
Correct Answer is B
Explanation
Choice A rationale
Cranial nerve I (olfactory) is responsible for smell, and cranial nerve II (optic) is responsible for vision. Cranial nerve V (trigeminal) is involved in facial sensation and mastication. These nerves are not primarily involved in controlling the extrinsic eye muscles responsible for eye movement.
Choice B rationale
Cranial nerve III (oculomotor) innervates the superior, inferior, and medial recti, and the inferior oblique muscles, and controls eyelid elevation. Cranial nerve IV (trochlear) innervates the superior oblique muscle. Cranial nerve VI (abducens) innervates the lateral rectus muscle. Together, these three cranial nerves precisely coordinate all six extraocular muscles for conjugate gaze.
Choice C rationale
While cranial nerve III (oculomotor) is correctly identified, cranial nerve V (trigeminal) and cranial nerve XI (accessory) are not primarily involved in eye movement. Cranial nerve V is involved in facial sensation and mastication, and cranial nerve XI innervates the sternocleidomastoid and trapezius muscles for head and shoulder movement.
Choice D rationale
Cranial nerve II (optic) is responsible for vision, transmitting visual information from the retina to the brain. Cranial nerve V (trigeminal) is involved in facial sensation and chewing. Cranial nerve VI (abducens) is correctly identified as innervating the lateral rectus, but the other two nerves listed do not control the majority of eye movements.
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