The nurse is performing a neurological assessment on a patient and elicits a positive Romberg’s sign. What observation by the nurse determines this outcome?

Choice A reason: Dorsiflexion and toe fanning indicate a Babinski sign, a reflex test, not Romberg’s sign. Romberg’s sign involves balance issues with closed eyes, so this is incorrect for the neurological assessment. Choice B reason: A positive Romberg’s sign is observed when a patient sways significantly or loses balance when standing with feet together and eyes closed, indicating impaired proprioception or cerebellar function. This is the correct observation for the test. Choice C reason: Rhythmic eye twitching (nystagmus) is unrelated to Romberg’s test, which assesses balance. Swaying with closed eyes defines a positive Romberg’s, sign, so this is incorrect for the outcome. Choice D reason: Inability to point fingers to a reference tests coordination, not the Romberg’s test, which focuses on balance with eyes closed. Significant swaying is the correct sign, so this is incorrect.