Which problem should the nurse expect for a patient who has a positive Romberg test result?

Confusion

Aphasia

Pain

Falls

Answer and Explanation

The Correct Answer is D

A. Confusion: While confusion may occur in some neurological conditions, it is not directly associated with a positive Romberg test result.

B. Aphasia: Aphasia refers to difficulty with language and communication and is typically associated with brain injury or stroke, not with a positive Romberg test result.

C. Pain: Pain is not directly assessed by the Romberg test. However, a positive Romberg test result may indicate sensory ataxia, which can contribute to difficulty with proprioception and coordination, potentially leading to increased risk of injury and pain.

D. Falls: A positive Romberg test result indicates impaired proprioception and balance,
increasing the risk of falls, especially in older adults or individuals with neurological conditions. This is the expected problem associated with a positive Romberg test result.

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Free Nursing Study Resources

Correct Answer is []

Explanation

The potential condition the client is most likely experiencing is a Hemorrhagic Stroke.

Prepare the client for a STAT CT brain: The client presents with sudden onset of severe headache described as the worst of their life, along with additional neurological symptoms such as left-sided weakness, aphasia, photophobia, and loss of peripheral vision. These symptoms are highly concerning for a possible hemorrhagic stroke, which requires urgent imaging such as a CT scan of the brain to confirm the diagnosis and guide immediate treatment.
Place the client on seizure precautions: The client has reported left-sided weakness and aphasia, indicating neurological deficits. Additionally, they have a history of atrialfibrillation and are on anticoagulant therapy with warfarin, resulting in an elevated INR of4.9. This INR level suggests a significantly increased risk of bleeding, including intracranial bleeding. Given these factors, the client is at risk of experiencing seizures, which is a potential complication of hemorrhagic stroke. Placing the client on seizure precautionsinvolves ensuring their safety and preventing injury in the event of a seizure.

Parameters to Monitor:

Temperature: Monitoring temperature is important to assess for the presence of fever, which could indicate an infectious process such as meningitis. However, in this case, theclient's fever is likely related to their urinary tract infection rather than directly related to the stroke. Nonetheless, monitoring temperature is still essential for overall assessment and management.
PT/INR: Monitoring the PT/INR is crucial due to the client's history of atrial fibrillation and anticoagulant therapy with warfarin. The elevated INR of 4.9 suggests that the client is at increased risk of bleeding, including intracranial bleeding. Close monitoring of PT/INR levels will help guide adjustments to anticoagulant therapy and assess the risk of further bleeding complications.

A. "An MRI scan is not distorted by movement, so you do not have to lie still." B. "The MRI contrast dye contains iodine and can cause your skin to itch." C. "An MRI scan is very noisy, and you will be allowed to wear earplugs while in the scanner." D. "An MRI scan is a short procedure and should take no longer than 30 minutes."

Correct Answer is C

Explanation

A. "An MRI scan is not distorted by movement, so you do not have to lie still." This statement is incorrect. Movement during an MRI scan can distort images and affect the quality of the diagnostic information obtained. Patients are typically instructed to lie as still as possible during the procedure.

B. "The MRI contrast dye contains iodine and can cause your skin to itch." This statement is incorrect. MRI contrast agents do not contain iodine and are not associated with itching.
However, some patients may experience allergic reactions to MRI contrast agents, but this is not related to iodine.

C. "An MRI scan is very noisy, and you will be allowed to wear earplugs while in the scanner." This statement is correct. MRI scanners produce loud noises during imaging, which can be bothersome to some patients. Patients are often provided with earplugs or headphones to help reduce the noise and make the experience more comfortable.

D. "An MRI scan is a short procedure and should take no longer than 30 minutes." This statement is incorrect. The duration of an MRI scan can vary depending on the type of imaging being performed and the specific protocol used. Some MRI scans may take longer than 30 minutes to complete.

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Which problem should the nurse expect for a patient who has a positive Romberg test result?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

A nurse is caring for a client who is scheduled to have a magnetic resonance imaging (MRI) scan. The client asks the nurse what to expect during the procedure. Which of the following statements should the nurse make?

Correct Answer is C

Explanation

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