When the nurse asks a 68-year-old patient to stand with his 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:
Positive Romberg sign.
Ataxia.
Lack of coordination.
Negative Homans sign.
The Correct Answer is A
A. A positive Romberg test occurs when a person loses balance or sways when standing with their eyes closed, indicating a problem with proprioception or balance.
B. Ataxia refers to a lack of coordination or motor control, but the Romberg sign specifically tests balance and proprioception, which is different from ataxia.
C. Lack of coordination may be part of ataxia or other neurological issues, but the Romberg sign specifically refers to balance issues when eyes are closed.
D. The Homans sign is used to test for deep vein thrombosis (DVT) and is not relevant to the test for balance and proprioception described in the scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D"]
Explanation
A. As the patient says a long "ee-ee-ee" sound, the examiner hears a long "aaaaaa" sound. - This indicates a possible consolidation in the lungs, which is abnormal.
B. When the patient speaks in a normal voice, the examiner can hear a sound but cannot exactly distinguish what is being said. - This suggests abnormal voice transmission and could indicate lung consolidation or other issues.
C. As the patient says a long "ee-ee-ee" sound, the examiner also hears a long "ee-ee-ee" sound. - This is normal, indicating clear and symmetrical transmission of voice sounds.
D. As the patient repeatedly says "ninety-nine," the examiner clearly hears the words "ninety-nine." - This is also normal, as it indicates normal transmission of sound and no lung consolidation.
E. Voice sounds are faint, muffled, and almost inaudible when the patient whispers "one, two, three" in a very soft voice. - This is normal for whispered voice sounds and is not a sign of abnormal lung findings.
Correct Answer is B
Explanation
A. While this is useful for clients who know sign language, it's important to first determine the communication method that the client prefers.
B. Each client may have different preferences or needs when it comes to communication, so it’s important to assess their preferred method before taking any further steps.
C. Speaking loudly is not effective and can distort words for those with hearing impairments. The focus should be on clear communication, such as lip-reading or using writing.
D. Facial and hand gestures can be helpful for communication, especially for individuals with hearing impairments. Avoiding them is unnecessary and could hinder understanding.
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