The nurse completes a Romberg's test on a patient with neurologic changes. The nurse will notify the provider if they observe which response?

Patient sways from side-to-side when standing with feet close together.

Patient's pupils do not respond equally to direct light from a flashlight.

Patient takes two attempts to touch their nose while their eyes are closed.

Patient complains of mild dizziness.

Answer and Explanation

The Correct Answer is A

Choice A reason: Swaying during a Romberg test indicates a positive result, suggesting proprioceptive deficits or sensory ataxia.

Choice B reason: Unequal pupil response to light relates to cranial nerve function, not balance assessed by the Romberg test.

Choice C reason: This is incorrect. Patient taking two attempts to touch their nose while their eyes are closed is a mild impairment of coordination, which may be due to neurologic changes or other factors such as fatigue or medication. This is not a significant finding that requires immediate attention.

Choice D reason: This is incorrect. Patient complaining of mild dizziness is a common symptom of neurologic changes or vestibular dysfunction. It is not a serious finding that requires immediate attention. The nurse should monitor the patient and provide comfort measures.

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Correct Answer is D

Explanation

Choice A reason: This is incorrect. Administering a dose of a prescribed antiepileptic drug is an appropriate intervention, but it should be done during the seizure, not after. Positioning the person supine is also not recommended, as it can compromise the airway and increase the risk of aspiration.

Choice B reason: This is incorrect. Wrapping the patient in warm blankets and hyperextending their neck are both harmful actions, as they can increase the body temperature and obstruct the airway. The patient should be kept cool and comfortable, and their head should be tilted to the side or supported with a pillow.

Choice C reason: This is incorrect. Offering the patient a crossword to work on to promote mental stimulation is not an essential intervention, and it may not be feasible or appropriate for a patient who has just experienced a prolonged seizure. The patient may need rest and observation, not cognitive tasks.

Choice D reason: This is correct. Establishing that the patient has a patent airway after the seizure ends and assessing for breathing are the most important interventions, as they ensure the oxygenation and ventilation of the patient. The nurse should also monitor the vital signs, neurological status, and blood glucose levels of the patient.

A. Flexion of the hip causes resistance to extension of the leg. B. Flexion of the neck causes flexion of the hips and knees. C. Flexion of the ankle causes upward fanning of the toes. D. Flexion of the neck causes pain and spasm in the leg muscles.

Correct Answer is B

Explanation

Choice A reason: Flexion of the hip causing resistance to extension of the leg is not a sign of meningitis. It is a sign of hip joint inflammation or injury.

Choice B reason: Flexion of the neck causing flexion of the hips and knees is a positive Brudzinski's sign. It indicates irritation of the meninges, the membranes that cover the brain and spinal cord.

Choice C reason: Flexion of the ankle causing upward fanning of the toes is not a sign of meningitis. It is a sign of an upper motor neuron lesion, such as a stroke or spinal cord injury.

Choice D reason: Flexion of the neck causing pain and spasm in the leg muscles is not a sign of meningitis. It is a sign of muscle strain or nerve compression.

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The nurse completes a Romberg's test on a patient with neurologic changes. The nurse will notify the provider if they observe which response?

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Naxlex Comprehensive Predictor Exams

The nurse should complete which essential interventions for a patient who has experienced status epilepticus?

Correct Answer is D

Explanation

The nurse assesses a patient who potentially may have meningitis. The patient demonstrates a positive Brudzinski's sign with which changes in position.

Correct Answer is B

Explanation

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