The nurse is examining a client experiencing vertigo and wants to perform the Romberg test. The nurse would correctly provide which set of instructions to the client?
1. "Touch your finger to your nose, alternating hands.".
2. "Walk across the room by placing one foot in front of the other, heel to toes.".
3. "Walk on your toes, then on your heels, then on your toes again.".
4. "Stand with your feet together, arms at sides, and eyes open.".
4
Rationale 1: The Romberg test is used to assess coordination and equilibrium. During the test the client is asked to stand with feet together, arms at sides, and eyes open. As the test progresses the client is asked to close her eyes. The amount of swaying done by the client once the eyes are closed is observed. Touching the finger to the nose with alternating hands is referred to as the finger-to-nose test and is used to assess coordination and equilibrium but is not the same as the Romberg test.
Rationale 2: Walking across the room in this manner describes tandem walking. This technique is used to observe gait.
Rationale 3: Walking in this manner enables the examiner to assess posture. The examiner should note the client's stance and the degree of stiffness or relaxation.
Rationale 4: The Romberg test is used to assess coordination and equilibrium. During the test the client is asked to close her eyes. The degree of swaying demonstrated is evaluated.
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