Know what the left temporal lobe of brain affects as far as the senses
1. 1. A nurse prepares to teach a client who has experienced damage to the left
... [Show More] temporal lobe of the brain. Which action should the nurse take when providing education about newly prescribed medications to this client?
a. Help the client identify each medication by its color.
b. Provide written materials with large print size.
c. Sit on the clients right side and speak into the right ear.
d. Allow the client to use a white board to ask questions.
Know what hypoactive deep tendon reflexes affect
2. A nurse plans care for a client who has a hypoactive response to a test of deep tendon reflexes. Which intervention should the nurse include in this clients plan of care?
a. Check bath water temperature with a thermometer.
b. Provide the client with assistance when ambulating.
c. Place elastic support hose on the clients legs.
d. Assess the clients feet for wounds each shift.
Know what things can interfere with MRI scans
10. A nurse obtains a focused health history for a client who is scheduled for magnetic resonance imaging (MRI). Which condition should alert the nurse to contact the provider and cancel the procedure?
a. Creatine phosphokinase (CPK) of 100 IU/L
b. Atrioventricular graft
c. Blood urea nitrogen (BUN) of 50 mg/dL
d. Internal insulin pump
14. After teaching a client who is scheduled for magnetic resonance imaging (MRI), the nurse assesses the clients understanding. Which client statement indicates a correct understanding of the teaching?
a. I must increase my fluids because of the dye used for the MRI.
b. My urine will be radioactive so I should not share a bathroom.
c. I can return to my usual activities immediately after the MRI.
d. My gag reflex will be tested before I can eat or drink anything.
Know what a single-photon emission computed tomography (SPECT) scan is and if there is any care required afterwards
20. A nurse cares for a client who is recovering from a single-photon emission computed tomography (SPECT) with a radiopharmaceutical agent. Which statement should the nurse include when discussing the plan of care with this client?
a. You may return to your previous activity level immediately.
b. You are radioactive and must use a private bathroom.
c. Frequent assessments of the injection site will be completed.
d. We will be monitoring your renal functions closely.
Know what imitrex is and any side effects associated with it
3. A nurse obtains a health history on a client prior to administering prescribed sumatriptan succinate (Imitrex) for migraine headaches. Which condition should alert the nurse to hold the medication and contact the health care provider?
a. Bronchial asthma
b. Prinzmetals angina
c. Diabetes mellitus
d. Chronic kidney disease
What is bacterial meningitis and how is it contracted?
9. A nurse obtains a focused health history for a client who is suspected of having bacterial meningitis. Which question should the nurse ask?
a. Do you live in a crowded residence?
b. When was your last tetanus vaccination?
c. Have you had any viral infections recently?
d. Have you traveled out of the country in the last month?
What are clinical manifestations of Parkinson’s?
10. After teaching the wife of a client who has Parkinson disease, the nurse assesses the wifes understanding. Which statement by the clients wife indicates she correctly understands changes associated with this disease?
a. His masklike face makes it difficult to communicate, so I will use a white board.
b. He should not socialize outside of the house due to uncontrollable drooling.
c. This disease is associated with anxiety causing increased perspiration.
d. He may have trouble chewing, so I will offer bite-sized portions.
11. A nurse plans care for a client with Parkinson disease. Which intervention should the nurse include in this clients plan of care?
a. Ambulate the client in the hallway twice a day.
b. Ensure a fluid intake of at least 3 liters per day.
c. Teach the client pursed-lip breathing techniques.
d. Keep the head of the bed at 30 degrees or greater.
Know patient/family teaching for Alzheimer’s and what the medications do
12. A nurse is teaching the daughter of a client who has Alzheimers disease. The daughter asks, Will the medication my mother is taking improve her dementia? How should the nurse respond?
a. It will allow your mother to live independently for several more years.
b. It is used to halt the advancement of Alzheimers disease but will not cure it.
c. It will not improve her dementia but can help control emotional responses.
d. It is used to improve short-term memory but will not improve problem solving.
13. A nurse assesses a client with Alzheimers disease who is recently admitted to the hospital. Which psychosocial assessment should the nurse complete?
a. Assess religious and spiritual needs while in the hospital.
b. Identify the clients ability to perform self-care activities.
c. Evaluate the clients reaction to a change of environment.
d. Ask the client about relationships with family members.
14. A nurse witnesses a client with late-stage Alzheimers disease eat breakfast. Afterward the client states, I am hungry and want breakfast. How should the nurse respond?
a. I see you are still hungry. I will get you some toast.
b. You ate your breakfast 30 minutes ago.
c. It appears you are confused this morning.
d. Your family will be here soon. Lets get you dressed.
16. A nurse cares for a client with advanced Alzheimers disease. The clients caregiver states, She is always wandering off. What can I do to manage this restless behavior? How should the nurse respond?
a. This is a sign of fatigue. The client would benefit from a daily nap.
b. Engage the client in scheduled activities throughout the day.
c. It sounds like this is difficult for you. I will consult the social worker.
d. The provider can prescribe a mild sedative for restlessness.
17. A nurse prepares to discharge a client with Alzheimers disease. Which statement should the nurse include in the discharge teaching for this clients caregiver?
a. Allow the client to rest most of the day.
b. Place a padded throw rug at the bedside.
c. Install deadbolt locks on all outside doors.
d. Provide a high-calorie and high-protein diet.
How do you treat lower back pain?
1. A nurse promotes the prevention of lower back pain by teaching clients at a community center. Which instruction should the nurse include in this education?
a. Participate in an exercise program to strengthen muscles.
b. Purchase a mattress that allows you to adjust the firmness.
c. Wear flat instead of high-heeled shoes to work each day.
d. Keep your weight within 20% of your ideal body weight.
2. A nurse plans care for a client with lower back pain from a work-related injury. Which intervention should the nurse include in this clients plan of care?
a. Encourage the client to stretch the back by reaching toward the toes.
b. Massage the affected area with ice twice a day.
c. Apply a heating pad for 20 minutes at least four times daily.
d. Advise the client to avoid warm baths or showers.
4. A nurse assesses clients at a community center. Which client is at greatest risk for lower back pain?
a. A 24-year-old female who is 25 weeks pregnant
b. A 36-year-old male who uses ergonomic techniques
c. A 45-year-old male with osteoarthritis
d. A 53-year-old female who uses a walker
What happens with spinal cord injuries at level T5? Clinical manifestations?
7. A nurse assesses a client with a spinal cord injury at level T5. The clients blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. Which action should the nurse take first?
a. Initiate oxygen via a nasal cannula.
b. Place the client in a supine position.
c. Palpate the bladder for distention.
d. Administer a prescribed beta blocker.
7. A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago. Which manifestations should the nurse correlate with neurogenic shock? (Select all that apply.)
a. Heart rate of 34 beats/min
b. Blood pressure of 185/65 mm Hg
c. Urine output less than 30 mL/hr
d. Decreased level of consciousness
e. Increased oxygen saturation
What happens in cervical spine injuries? Clinical manifestations?
8. An emergency room nurse initiates care for a client with a cervical spinal cord injury who arrives via emergency medical services. Which action should the nurse take first?
a. Assess level of consciousness.
b. Obtain vital signs.
c. Administer oxygen therapy.
d. Evaluate respiratory status.
What is the purpose of rehabilitation for patients with paraplegia?
11. A nurse is caring for a client with paraplegia who is scheduled to participate in a rehabilitation program. The client states, I do not understand the need for rehabilitation; the paralysis will not go away and it will not get better. How should the nurse respond?
a. If you dont want to participate in the rehabilitation program, Ill let the provider know.
b. Rehabilitation programs have helped many clients with your injury. You should give it a chance.
c. The rehabilitation program will teach you how to maintain the functional ability you have and prevent further disability.
d. When new discoveries are made regarding paraplegia, people in rehabilitation programs will benefit first.
6. A nurse assesses a client with paraplegia from a spinal cord injury and notes reddened areas over the clients hips and sacrum. Which actions should the nurse take? (Select all that apply.)
a. Apply a barrier cream to protect the skin from excoriation.
b. Perform range-of-motion (ROM) exercises for the hip joint.
c. Re-position the client off of the reddened areas.
d. Get the client out of bed and into a chair once a day.
e. Obtain a low-air-loss mattress to minimize pressure.
What are the clinical manifestations of early multiple sclerosis (MS)?
13. A nurse assesses a client with early-onset multiple sclerosis (MS). Which clinical manifestation should the nurse expect to find?
a. Hyperresponsive reflexes
b. Excessive somnolence
c. Nystagmus
d. Heat intolerance
Know what Gilenya medication is used for and any side effects that can be caused
15. A nurse assesses a client with multiple sclerosis after administering prescribed fingolimod (Gilenya). For which adverse effect should the nurse monitor?
a. Peripheral edema
b. Black tarry stools
c. Bradycardia
d. Nausea and vomiting
Know the late clinical manifestation of ALS
17. A nurse assesses a client with a neurologic disorder. Which assessment finding should the nurse identify as a late manifestation of amyotrophic lateral sclerosis (ALS)?
a. Dysarthria
b. Dysphagia
c. Muscle weakness
d. Impairment of respiratory muscles
What is Guillain-Barre? What are the clinical manifestations? How is it treated?
1. A client is admitted with Guillain-Barr syndrome (GBS). What assessment takes priority?
a. Bladder control
b. Cognitive perception
c. Respiratory system
d. Sensory functions
2. The nurse learns that the pathophysiology of Guillain-Barr syndrome includes segmental demyelination. The nurse should understand that this causes what?
a. Delayed afferent nerve impulses
b. Paralysis of affected muscles
c. Paresthesia in upper extremities
d. Slowed nerve impulse transmission
3. A client with Guillain-Barr syndrome is admitted to the hospital. The nurse plans caregiving priority to interventions that address which priority client problem?
a. Anxiety
b. Low fluid volume
c. Inadequate airway
d. Potential for skin breakdown
12. An older client is hospitalized with Guillain-Barr syndrome. A family member tells the nurse the client is restless and seems confused. What action by the nurse is best?
a. Assess the clients oxygen saturation.
b. Check the medication list for interactions.
c. Place the client on a bed alarm.
d. Put the client on safety precautions.
4. An older adult client is hospitalized with Guillain-Barr syndrome. The client is given amitriptyline (Elavil). After receiving the hand-off report, what actions by the nurse are most important? (Select all that apply.)
a. Administering the medication as ordered
b. Advising the client to have help getting up
c. Consulting the provider about the drug
d. Cutting the dose of the drug in half
e. Placing the client on safety precautions
5. The nurse caring for a client with Guillain-Barr syndrome has identified the priority client problem of decreased mobility for the client. What actions by the nurse are best? (Select all that apply.)
a. Ask occupational therapy to help the client with activities of daily living.
b. Consult with the provider about a physical therapy consult.
c. Provide the client with information on support groups.
d. Refer the client to a medical social worker or chaplain.
e. Work with speech therapy to design a high-protein diet.
How do patients protect their eyes? What teaching can we provide?
1. The nurse has given a community group a presentation on eye health. Which statement by a participant indicates a need for more instruction?
a. I always lose my sunglasses, so I dont wear them.
b. I have diabetes and get an annual eye exam.
c. I will not share my contact solution with others.
d. I will wear safety glasses when I mow the lawn.
Know the normal range for the IOP
5. A clients intraocular pressure (IOP) is 28 mm Hg. What action by the nurse is best?
a. Educate the client on corneal transplantation.
b. Facilitate scheduling the eye surgery.
c. Plan to teach about drugs for glaucoma.
d. Refer the client to local Braille classes.
What should we teach patients about eye drops? How do they instill eye drops?
2. A client is seen in the ophthalmology clinic with bacterial conjunctivitis. Which statements by the client indicate a good understanding of home management of this condition? (Select all that apply.)
a. As long as I dont wipe my eyes, I can share my towel.
b. Eye irrigations should be done with warm saline or water.
c. I will throw away all my eye makeup when I get home.
d. I wont touch the tip of the eyedrop bottle to my eye.
e. When the infection is gone, I can use my contacts again.
How do you treat external otitis?
5. A client has external otitis. On what comfort measure does the nurse instruct the client?
a. Applying ice four times a day
b. Instilling vinegar-and-water drops
c. Use of a heating pad to the ear
d. Using a home humidifier
What are the steps for instilling ear drops?
10. A nursing student is instructed to remove a clients ear packing and instill eardrops. What action by the student requires intervention by the registered nurse?
a. Assessing the eardrum with an otoscope
b. Inserting a cotton ball in the ear after the drops
c. Warming the eardrops in water for 5 minutes
d. Washing the hands and removing the packing
What should you teach patients concerning how to prevent hearing loss?
13. A nurse is teaching a community group about preventing hearing loss. What instruction is best?
a. Always wear a bicycle helmet.
b. Avoid swimming in ponds or lakes.
c. Dont go to fireworks displays.
d. Use a soft cotton swab to clean ears.
What is mastoiditis and what complications can occur from it?
Know what labs to check with diabetes and polyuria
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1.A nurse is teaching a client with diabetes mellitus who asks, Why is it necessary to maintain my blood glucose levels no lower than about 60 mg/dL? How should the nurse respond?
a. Glucose is the only fuel used by the body to produce the energy that it needs.
b. Your brain needs a constant supply of glucose because it cannot store it.
c. Without a minimum level of glucose, your body does not make red blood cells.
d. Glucose in the blood prevents the formation of lactic acid and prevents acidosis.
2.A nurse reviews laboratory results for a client with diabetes mellitus who presents with polyuria, lethargy, and a blood glucose of 560 mg/dL. Which laboratory result should the nurse correlate with the clients polyuria?
a. Serum sodium: 163 mEq/L
b. Serum creatinine: 1.6 mg/dL
c. Presence of urine ketone bodies
d. Serum osmolarity: 375 mOsm/kg
Know what to teach patients about controlling their diabetes and why they should control it
6.A nurse teaches a client who is diagnosed with diabetes mellitus. Which statement should the nurse include in this clients plan of care to delay the onset of microvascular and macrovascular complications?
a. Maintain tight glycemic control and prevent hyperglycemia.
b. Restrict your fluid intake to no more than 2 liters a day.
c. Prevent hypoglycemia by eating a bedtime snack.
d. Limit your intake of protein to prevent ketoacidosis.
36.After teaching a client with type 2 diabetes mellitus, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching?
a. I need to have an annual appointment even if my glucose levels are in good control.
b. Since my diabetes is controlled with diet and exercise, I must be seen only if I am sick.
c. I can still develop complications even though I do not have to take insulin at this time.
d. If I have surgery or get very ill, I may have to receive insulin injections for a short time.
36.After teaching a client with type 2 diabetes mellitus, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching?
a. I need to have an annual appointment even if my glucose levels are in good control.
b. Since my diabetes is controlled with diet and exercise, I must be seen only if I am sick.
c. I can still develop complications even though I do not have to take insulin at this time.
d. If I have surgery or get very ill, I may have to receive insulin injections for a short time.
How is insulin stored?
15.A nurse cares for a client with diabetes mellitus who is visually impaired. The client asks, Can I ask my niece to prefill my syringes and then store them for later use when I need them? How should the nurse respond?
a. with the needle pointing up.
b. Yes. Syringes can be filled with insulin and stored for a month in a location that is protected from light.
c. Insulin reacts with plastic, so prefilled syringes are okay, but you will need to use glass syringes.
d. No. Insulin syringes cannot be prefilled and stored for any length of time outside of the container.
What causes Kussmaul respirations and what is it?
20.A nurse cares for a client experiencing diabetic ketoacidosis who presents with Kussmaul respirations. Which action should the nurse take?
a. Administration of oxygen via face mask
b. Intravenous administration of 10% glucose
c. Implementation of seizure precautions
d. Administration of intravenous insulin
2.A nurse assesses a client who is experiencing diabetic ketoacidosis (DKA). For which manifestations should the nurse monitor the client? (Select all that apply.)
a. Deep and fast respirations
b. Decreased urine output
c. Tachycardia
d. Dependent pulmonary crackles
e. Orthostatic hypotension
Know how to detect decreased kidney function and know the normal value for urine specific gravity
29.A nurse assesses a client with diabetes mellitus. Which clinical manifestation should alert the nurse to decreased kidney function in this client?
a. Urine specific gravity of 1.033
b. Presence of protein in the urine
c. Elevated capillary blood glucose level
d. Presence of ketone bodies in the urine
Know which electrolytes are affected by insulin and why
32.A nurse reviews the laboratory results of a client who is receiving intravenous insulin. Which should alert the nurse to intervene immediately?
a. Serum chloride level of 98 mmol/L
b. Serum calcium level of 8.8 mg/dL
c. Serum sodium level of 132 mmol/L
d. Serum potassium level of 2.5 mmol/L
Know which medications are safe or not safe to give after IV contrast has been given (Actos, Amaryl, Glucotrol, Glucophage)
39.A nurse reviews the medication list of a client recovering from a computed tomography (CT) scan with IV contrast to rule out small bowel obstruction. Which medication should alert the nurse to contact the provider and withhold the prescribed dose?
a. Pioglitazone (Actos)
b. Glimepiride (Amaryl)
c. Glipizide (Glucotrol)
d. Metformin (Glucophage)
Know the normal ranges for : Fasting blood glucose, postprandial blood glucose, hemoglobin A1C
41.A nurse reviews laboratory results for a client with diabetes mellitus who is prescribed an intensified insulin regimen:
Fasting blood glucose: 75 mg/dL
Postprandial blood glucose: 200 mg/dL
Hemoglobin A1c level: 5.5%
How should the nurse interpret these laboratory findings?
a. Increased risk for developing ketoacidosis
b. Good control of blood glucose
c. Increased risk for developing hyperglycemia
d. Signs of insulin resistance
Know complications that occur after an implantation of a vagal nerve-stimulation device
8. A nurse assesses a client who is recovering from the implantation of a vagal nerve stimulation device. For which clinical manifestations should the nurse assess as common complications of this procedure? (Select all that apply.)
a. Bleeding
b. Infection
c. Hoarseness
d. Dysphagia
e. Seizures
Know what meningitis is and what lab values can be affected
9. A nurse is caring for a client with meningitis. Which laboratory values should the nurse monitor to identify potential complications of this disorder? (Select all that apply.)
a. Sodium level
b. Liver enzymes
c. Clotting factors
d. Cardiac enzymes
e. Creatinine level
Know the care of a patient wearing a halo fixator
8. A nurse plans care for a client with a halo fixator. Which interventions should the nurse include in this clients plan of care? (Select all that apply.)
a. Tape a halo wrench to the clients vest.
b. Assess the pin sites for signs of infection.
c. Loosen the pins when sleeping.
d. Decrease the clients oral fluid intake.
e. Assess the chest and back for skin breakdown.
Know what Meniere’s disease is and the clinical manifestations
No answer for this oneMeniere’s disease usually first occurs in people between the age of 20 and 50y/o. Its has 3 features tinnitus, one -sided sensor neural auditory sensory perception loss and vertigo, occurring in attacks that can last for several days.
Meniere disease is an excess of endolymphatic fluid that distorts the entire inner ear canal system. This distortion decreases hearing by dilating the cochlear duct, causes vertigo b/c of the damage to the vestibular system and stimulates tinnitus.
S/S headache, increasing tinnitus, and fullness of the affected ear can precede the attack of vertigo. Tinnitus as a continous, low pitched roar or a humming sound, which worsens just before and during an attack.
1. A client presents to the ED reporting foreign body in eye. What diagnostic testing would nurse prepare?
2. Nurse admonsters eyedrops to client with infection in r eye. Drops go in both eyes, 2 diff bottles used. Nurse accidentally uses the l bottle for the r eye. What action is best?
3. Pt doesn’t understand why vision loss due to glaucoma is irreversible. What explanation best?
4. Pt IOP is 28 mmhg. (12-22 norm) What action is best?
5. Pt had a retinal detachment and undergone surgical correction. Discharge info most important?
6. Pt is taking timolol (timoptic) eyedrops. Nurse assess pt pulse at 48 bpm. What action is priority?
7. Nurse is teaching pt about ear hygiene and health. What pt statement indicates need further teaching?
8. Nurse is teaching pt w diabetes who asks why is it necessary to maintain blood glucose levels no lower than 60. How would nurse respond?
9. Nurse cares for a pt who has a family history of diabetes. Pt states my father has type 1, will I develop. How would nurse respond?
10. Nurse assess pts who are at risk for diabetes. Which pt is at greatest risk?
11. Nurse teaches a pt with type 2 diabetes who is prescribed glipizide (Glucotrol) which statement would the nurse include in pt teaching?
12. After teaching a pt with type 2 diabetes who is prescribed nateglinide (starlix) nurse assess the pt’s understanding. Which statement made by pt indicates correct understanding of therapy?
13. Nurse assess a pt with diabetes and notes that the pt on responds to sternal rub by moaning, cap blood glucose of 33, IV line that is infiltrated with 0.45% NS. What action?
14. Nurse cares for pt experiencing DKA who presents w kussmual respirations. What action would you take?
15. Nurse teaches a pt with type 1 diabetes. Which statement would the nurse include in the pt’s teaching to decrease the pt’s insulin needs?
16. Nurse assess a pt with diabetes 3 hours after a surgical procedure & notes that the pt breath has a fruity odor. What action should you take?
17. Nurse teaches a pt w diabetes who is expericing numbness and reduced senation. Which statement nurse include in teaching to prevent injury?
18. Nurse reviews the med list of a pt with 20 year history of diabetes. Pt holds up the bottle of persscribed duloxetine (Cymbalta) & states my cousin has depression & is taking this drug. Do you think im depressed? How would nurse respond?
19. Nurse asses pt who has diabetes and notes the pt is awake/alert. Shaky, diaphoretic, weak. 5 mins adter administering half cup of OJ the pt manifestations haven’t changed. Action?
20. Nurse reviews labs result of pt who is receiving IV insulin. Which would alert nurse immediately?
21. When teaching a pt recently diagnosed w type 1, I will never be able to stick self w needle.
22. Nurse prepares to admin insulin at 1800. Pt record: insulin 12 units daily 1800, reg insulin 6 units QID 6, 1800, 2400.
23. Nurse prepares to admin prescribed reg insulin &NPH insulin. Place the nurses actions in correct order to admin. .
24. Nurse reviews chart and new prescription with pt with DKA.
25. Nursing student learns that age related changes affects eyes and visions. Which changes does this include?
26. Nurse is teaching older adults at a senior center about changes to the ears that occur with aging. Which instruction should the nurse include?
27. Nurse provides diabetic education at a public health fair. Which disorders would the nurse include as complications of diabetes?
A patient in the family practice clinic has restless leg syndrome. Routine laboratory work reveals white blood cells 8000mm3 (8x10^9 L); magnesium 0.8mEq/L (0.4mmol/L), and sodium 138 mEq/L (138mmol/L). What action by the nurse is best?
A patient is taking long-term corticosteroids for myasthenia gravis. What teaching is most important?
The nurse is preparing a patient for a Tensilon (edrophonium chloride) test. What action by the nurse is most important?
A nurse cares for a patient with amyotrophic lateral sclerosis (ALS). The patient states “I do not want to be placed on a mechanical ventilator.” How would the nurse respond?
A nurse teaches a patient with a lower motor neuron lesion who wants to achieve bladder control. Which statement would the nurse include in this patient’s teaching?
A nurse assesses a patient who is recovering from anterior cervical discectomy and fusion. Which complication would alert the nurse to urgently communicate with the healthcare provider?
A nurse delegates care for a client with early stage Alzheimer’s disease to an unlicensed assistive personnel (UAP). Which statement would the nurse include when delegating this client’s care?
A nurse delegates care for a client with Parkinson disease to an unlicensed assistive personnel (UAP). Which statement would the nurse include when delegating this client’s care?
A nurse is teaching care to the unlicensed assistive personel (UAP). Which statement would the nurse include when delegating care for a patient with cranial nerve II impairment?
A nurse is teaching a patient with cerebellar function impairment. Which statement would the nurse include in this patient’s discharge teaching?
A nurse performs an assessment of pain discrimination on an older adult patient. The patient correctly identifies, with eyes closed, a sharp sensation on the right hand when touched with a pin. Which action would the nurse take next?
A nurse plans care for an 83-year old patient who is experiencing age-related sensory perception changes. Which intervention would the nurse include in this patient’s plan of care?
A nurse obtains a focused health history for a patient who is scheduled for magnetic resonance angiography. Which priority question would the nurse ask before the test?
A nurse asks a patient to take deep breaths during an electroencephalography. The patient asks, “Why are you asking me to do this?” how would the nurse respond?
A nurse assesses a patient who demonstrates a positive Romberg’s sign with eyes closed but not with eyes open. Which condition does the nurse associate with this finding? [Show Less]