NURSING ATI 190 ASS. FINAL
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NURSING ATI 190 ASS. FINAL Physical assessment final 1. Think about Romberg’s test. What is your intervention to keep the patient safe? Think about falls. The nurse is performing the Romberg te... st and asks the client to stand with the feet together and eyes closed. The nurse notes the findings are normal. Which finding is expected during this assessment? 1. Swaying from side to side. 2. Exhibiting minimal swaying. 3. Feeling moderately dizzy. 4. Having complete loss of balance. Rationale 2: The Romberg test is used to test coordination and equilibrium. During the test, the client is asked to stand with feet together and arms at the sides. A minimal amount of swaying is normal. The nurse is caring for a client experiencing vertigo and plans to perform the Romberg test during the assessment. Which instruction from the nurse regarding this test is the most appropriate? 1. “Touch your finger to your nose, alternating hands.” 2. “Walk across the room by placing one foot in front of the other, heel to toes.” 3. “Walk on your toes, then on your heels, then on your toes again.” 4. “Stand with your feet together, arms at sides, and eyes open.” Correct Answer: 4 Rationale 4: The Romberg test is used to assess coordination and equilibrium. During the test the client is asked to close her eyes. The degree of swaying demonstrated is evaluated. Page 775. Romberg’s test assesses coordination and equilibrium (cranial nerve VIII) 1. Ask the patient to stand with feet together and arms at sides. The patient’s eyes are open. 2. Stand next to the patient to prevent falls. Observe for swaying 3. Ask the client to close both eyes without changing position 4. Observe for swaying while the patient’s eyes are closed. Swaying normally increases slightly when the eyes are closed. A positive Romberg’s test sign occurs when swaying greatly increases or the patient experiences difficult maintaining his or her balance. This may indicate disease of the posterior column of the spinal cord. 2. If you have a head injury. What is your sign that you have bleeding in your brain? The nurse is assessing a client that experienced a head injury using the Glasgow Coma Scale. Which findings are scored using the best motor response portion of the scale? Standard Text: Select all that apply. 1. No response with eyes to commands. 2. Abnormal flexion to pain. 3. Pupil response sluggish. 4. Abnormal extension to pain. 5. Pupils fixed and dilated. [Show More]
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