When the nurse asks an older 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. How should the nurse document this finding?
Positive Homan sign
Lack of coordination
Positive Romberg sign
Ataxia
The Correct Answer is C
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
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.
Correct Answer is D
Explanation
Choice A reason: Simultaneously palpating both carotid arteries is dangerous, risking reduced cerebral blood flow, especially in cardiovascular patients. Using the bell to listen for bruits is safer, so this is incorrect.
Choice B reason: Deep breaths are for lung auscultation, not carotid, where patients hold breath to reduce noise. The bell detects low-pitched bruits, so instructing deep breaths is incorrect for carotid assessment.
Choice C reason: Compressing the carotid artery risks reducing blood flow or dislodging plaques, which is unsafe. Listening with the bell for bruits is the standard method, so this is incorrect.
Choice D reason: Listening with the bell of the stethoscope detects low-frequency bruits, indicating carotid artery narrowing, which is critical in cardiovascular disease. This is the correct technique for safe assessment.
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