When standing with their eyes closed, feet together, and arms at their sides, a patient sways and starts to fall. How should the nurse document this finding?

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The Romberg test is an assessment of posture and balance (cerebellar function). Abnormal findings occur when the person sways, falls, or widens the base of the feet to avoid falling. A positive Romberg sign is loss of balance that occurs when closing the eyes and occurs with cerebellar ataxia, loss of proprioception, and loss of vestibular function. A positive Babinski sign is an abnormal superficial reflex response. Ortolani sign tests hip stability. A modified Allen test is used to evaluate the adequacy of collateral circulation before cannulating the radial artery.

When Standing with Their Eyes Closed, Feet Together, and Arms