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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Correct Answer is B

Explanation

A. Oriented to person, place, and year: Meningitis often causes alterations in mental status, including confusion and disorientation. Therefore, the client may not be fully oriented to person, place, and time.

B. Severe headache: Headache is a hallmark symptom of meningitis and is often described as severe and persistent. It may be accompanied by other symptoms such as photophobia (sensitivity to light) and phonophobia (sensitivity to sound).

C. Bradycardia: Bradycardia is not typically associated with meningitis. In fact, tachycardia (elevated heart rate) may be present due to fever and systemic inflammation.

D. Blurred vision: While meningitis can lead to increased intracranial pressure, which may manifest as papilledema (swelling of the optic disc), blurred vision is not a common presenting symptom of meningitis. Visual changes are more commonly associated with conditions affecting the optic nerve or retina.

A. Obtain the client's heart rate. B. Administer a nitrate antihypertensive. C. Place the client in a high-Fowler's position. D. Assess the client for bladder distention.

Correct Answer is D

Explanation

A. Obtain the client's heart rate: While obtaining the client's heart rate is important in the assessment of autonomic dysreflexia, assessing for and addressing the underlying cause take precedence.

B. Administer a nitrate antihypertensive: Administering antihypertensive medication may be necessary if autonomic dysreflexia is confirmed, but it is not the first action to take. Addressing the cause of autonomic dysreflexia, such as bladder distention, is the priority.

C. Place the client in a high-Fowler's position: Elevating the client's head may help reduce blood pressure, but it does not address the underlying cause of autonomic dysreflexia. Assessing for and addressing the cause, such as bladder distention, is the priority.

D. Assess the client for bladder distention: Autonomic dysreflexia is commonly triggered by stimuli below the level of spinal cord injury, such as bladder distention. Assessing the client's bladder for distention and addressing any urinary retention or obstruction is the first action to take in managing autonomic dysreflexia.

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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

A nurse is assessing a client who has meningitis. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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