When the nurse asks a 68-year-old patient to stand with his feet ...

[123654777]

When the nurse asks a 68-year-old patient to stand with his feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. The nurse would document this finding as:
 
  a. Ataxia.
  b. Lack of coordination.
  c. Negative Homans sign.
  d. Positive Romberg sign.

Question 2

During the neurologic assessment of a healthy 35-year-old patient, the nurse asks him to relax his muscles completely. The nurse then moves each extremity through full range of motion. Which of these results would the nurse expect to find?
 
  a. Firm, rigid resistance to movement
  b. Mild, even resistance to movement
  c. Hypotonic muscles as a result of total relaxation
  d. Slight pain with some directions of movement

[sarah_brady415]

Answer to Question 1

ANS: D
Abnormal findings for the Romberg test include swaying, falling, and a widening base of the feet to avoid falling. A positive Romberg sign is a loss of balance that is increased by the closing of the eyes. Ataxia is an uncoordinated or unsteady gait. Homans sign is used to test the legs for deep-vein thrombosis.

Answer to Question 2

ANS: B
Tone is the normal degree of tension (contraction) in voluntarily relaxed muscles. It shows a mild resistance to passive stretching. Normally, the nurse will notice a mild, even resistance to movement. The other responses are not correct.