The nurse plans care for a client who has a positive Romberg test. The nurse will prioritize which intervention?

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11ecbb05_cb66_914d_b433_75e7a696f453_MD0009_00 The Romberg test, part of a focused neurologic examination, assesses clients' perceptions of their head in space (vestibular function) and body in space (proprioception). It is used to determine the reason for loss of coordination (ataxia). Clients are asked to stand with the feet together and hands at the sides of the body. They are then asked to close their eyes while ability to maintain balance is assessed. A loss of balance is considered to be a positive Romberg sign and indicates that ataxia is sensory in nature rather than cerebellar. Clients demonstrating a positive Romberg test are likely to have ataxia, or be prone to lose balance, and would require assistance with ambulation. (Option A) Damage to the glossopharyngeal and vagus nerves (cranial nerves IX and X) would cause problems with swallowing and the gag reflex. (Option C) Providing for sensory stimulation is important in many disorders of the neurologic system. However, this would not be needed for a client with a positive Romberg test. (Option D) Speaking at a normal voice while facing a client directly is a measure used for those with hearing loss. Educational objective: A client with a positive Romberg test has a loss of sense of self in space and needs assistance with ambulation to prevent injury and provide safety.

The Nurse Plans Care for a Client Who Has a Positive