NURS 190 Physical Assessment final week 8 Exam.1. Think about Romberg’s test. What is your intervention to keep the patient safe?
Think about
... [Show More] falls.
The nurse is performing the Romberg test 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.
Correct Answer: 2, 4
Rationale 2: No verbal response. This finding is for the motor response portion of the scale. The
Glascow Coma Scale assesses level of consciousness on a continuum from alertness to coma. The
scale tests verbal, eye opening, and motor response. The client may score between 3 and 15
points with the tool.
Rationale 4: No motor movement. This finding is for the motor response portion of the scale.
The Glascow Coma Scale assesses level of consciousness on a continuum from alertness to coma.
The scale tests verbal, eye opening, and motor response. The client may score between 3 and 15
points with the tool.
Page 787-788 Use the Glasgow Coma Scale
The Glasgow Coma Scale assesses the level of consciousness of the individual on a continuum
from alertness to coma. The scale test three body functions, verbal response, motor response,
and eye response. A maximum total score of 15 indicates the person is alert, responsive and
oriented. A total score of 3, the lowest achievable score indicates a no responsible comatose
individual.
3. If you have had a head injury and you have someone lying on the bread. Think
CSF page 340
The client has been brought via ambulance to the emergency department (ED) following a motor
vehicle accident. The nurse notes that the client’s ear is draining clear fluid. Which is the priority
nursing action?
1. Requesting information from the client regarding any chronic allergies.
2. Testing the drainage for glucose.
3. Asking the client if there have been recent middle ear infections.
4. Irrigating the ear with warm mineral oil or peroxide, and flushing with warm water.
Correct Answer: 2
Global Rationale: When a client’s ear is draining clear fluid, this might indicate the client has a
cerebrospinal fluid leak. The fluid should be tested for glucose. Glucose is present in
cerebrospinal fluid.
4. Neuro assessment. Know the term sterogenesis. Dropping a dime. Pt should be able
to know. Page 780
Test stereognosis is the ability to identify an object without seeing it.
The nurse is performing a neurological assessment on a client and needs to use stereognosis.
Which instruction would the nurse provide for the client?
1. “Tell me if you feel one or two objects touching you with your eyes closed.”
2. “Identify the object in your hand with your eyes closed.”
3. “Identify the number being traced in your hand with your eyes closed.”
4. “Open and close your hand each time I tell you to.”
Correct Answer: 2
5. Know Babinski test. Page 786
Babinski response is the fanning of the toes with the great toe pointing toward the dorsum of the
food. This is called dorsi-flexion of the toe and is considered an abnormal response in the adult. If
may indicate upper motor neuron disease.
A positive Babiski response is considered a normal response in the child until about 2 years of
age. [Show Less]