The nurse is providing care for an 87-year-old woman who is recovering from a cerebral vascular accident. Which of the following precautions should the nurse take after noting the patient has a positive Romberg test?

Question

Quizplus · Accepted Answer

The Romberg test assesses a patient's ability to maintain balance while standing with their eyes closed. A positive Romberg test indicates an increased risk of falls. Therefore, fall-risk precautions should be instituted to prevent falls, such as bed rails up, placing the call light within reach, and encouraging the patient to use the call light for assistance with all activities. Providing small, frequent meals (A) may be appropriate for a patient with dysphagia or decreased appetite, but it is not directly related to the positive Romberg test. Darkening the room and reducing stimuli (C) may be appropriate for a patient who is experiencing sensory overload, but it is not directly related to the positive Romberg test. Requesting a footboard and splints (D) may be appropriate for a patient who is at risk for foot drop, but it is not directly related to the positive Romberg test.

The Nurse Is Providing Care for an 87-Year-Old Woman Who