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

Answer and Explanation

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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Correct Answer is B

Explanation

Choice A reason: Reading handheld print tests reading near vision, not standard visual acuity, which requires distance assessment. The Snellen chart at 20 feet is the standard, so this is incorrect for acuity testing.

Choice B reason: The Snellen chart, positioned 20 feet away, is the standard method for assessing visual acuity in adolescents, providing a reliable measure of distance vision. This is the correct procedure for the nurse.

Choice C reason: The confrontation test assesses peripheral vision, not central acuity. The Snellen chart measures sharpness of vision, so this is incorrect for the purpose of visual acuity assessment.

Choice D reason: Reading newsprint at 12–14 inches tests near vision, not distance acuity, which is the standard for screening. The Snellen chart at 20 feet is appropriate, so this is incorrect.

A. Bronchial breath sounds that are normal in that location B. Normal sounds auscultated over the trachea C. Vesicular breath sounds that are normal in that location D. Bronchovesicular breath sounds that are normal in that location

Correct Answer is C

Explanation

Choice A reason: Bronchial breath sounds are loud, high-pitched, with expiration longer than inspiration, typically heard over the trachea or in consolidated lung areas. The described soft, low-pitched sounds with longer inspiration in the posterior lower lobes do not match, making this incorrect.

Choice B reason: Sounds over the trachea are bronchial, characterized by loud, high-pitched sounds with expiration equal to or longer than inspiration. The soft, low-pitched sounds with longer inspiration in the posterior lower lobes indicate peripheral lung fields, not tracheal sounds, making this incorrect.

Choice C reason: Vesicular breath sounds are soft, low-pitched, with inspiration longer than expiration, heard over peripheral lung fields like the posterior lower lobes. These are normal findings, reflecting air movement in alveoli, making this the correct interpretation of the described sounds.

Choice D reason: Bronchovesicular sounds are medium-pitched with equal inspiration and expiration, typically heard near mainstem bronchi. The described low-pitched sounds with longer inspiration in the posterior lower lobes align with vesicular sounds, not bronchovesicular, making this incorrect.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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