During the performance of the Romberg test, the nurse observes that the patient sways slightly. What is the nurse's most appropriate action?
A) Facilitate a referral to a neurologist.
B) Reposition the patient supine to ensure safety.
C) Document successful completion of the assessment.
D) Follow up by having the patient perform the Rinne test.
Ans: C
Feedback:
Slight swaying during the Romberg test is normal, but a loss of balance is abnormal and is considered a positive Romberg test. Slight swaying is not a significant threat to the patient's safety. The Rinne test assesses hearing, not balance.
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