An older patient is being assessed by the nurse. Which finding does the nurse consider abnormal when assessing the patient's risk for fall?
a. Use of an assistive device
b. Wearing glasses
c. Failure of the Get Up and Go test
d. Negative Romberg's test
C
The Get Up and Go test is an assessment that should be conducted as part of a routine evaluation of older adults. The test detects people at risk for falling.
The Romberg's reflex is normally negative, meaning that when the patient stands with feet to-gether, arms down at sides, and eyes open (20-30 seconds) or closed (20-30 seconds), there is minimal to no swaying. Using an assistive device or wearing glasses does not put the patient at risk for falling unless they are not using their devices.
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