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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Deep-vein thrombophlebitis involves deep vein inflammation and clotting, causing pain, swelling, and warmth, but not typically visible dilated veins. The described tortuous veins are superficial, not deep, making this an incorrect diagnosis for the findings.
Choice B reason: Varicose veins are dilated, tortuous superficial veins, often in the lower legs, causing heaviness or aching. These result from venous insufficiency, leading to blood pooling, which matches the patient’s visible veins and symptoms, making this correct.
Choice C reason: Peripheral artery disease causes reduced arterial blood flow, leading to pain, pallor, or claudication, not dilated veins. The visible tortuous veins suggest a venous issue, not arterial, making this an incorrect condition for the findings.
Choice D reason: Chronic lymphedema causes swelling due to lymphatic fluid accumulation, typically without dilated veins. The patient’s tortuous veins and heaviness point to venous pathology, not lymphatic, making this an incorrect diagnosis for the described symptoms.
Correct Answer is B
Explanation
Choice A reason: Herniated brainstem causes bilateral pupil changes and severe neurological signs, not unilateral dilation. Unilateral pupil dilation suggests increased intracranial pressure, so this is incorrect for these findings.
Choice B reason: Unilateral pupil dilation and nonreactivity, as seen in the right pupil, indicate increased intracranial pressure, often from mass effect compressing the oculomotor nerve. This is critical, making it the correct finding.
Choice C reason: Subdural hemorrhage may cause pressure but isn’t specific to these pupil changes. Unilateral dilation points to increased intracranial pressure as the immediate concern, so this is less precise.
Choice D reason: Cerebral edema contributes to pressure but is a broader term. Unilateral pupil dilation specifically suggests increased intracranial pressure, a more immediate and precise diagnosis, so this is incorrect.
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