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    Ati nurs 220 health assessment proctored exam

    When the nurse asks a 68-year-old patient to stand with his feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. The nurse would document this finding as:

    Explanation & Rationale

    A. A positive Romberg test occurs when a person loses balance or sways when standing with their eyes closed, indicating a problem with proprioception or balance. B. Ataxia refers to a lack of coordination or motor control, but the Romberg sign specifically tests balance and proprioception, which is different from ataxia. C. Lack of coordination may be part of ataxia or other neurological issues, but the Romberg sign specifically refers to balance issues when eyes are closed. D. The Homans sign is used to test for deep vein thrombosis (DVT) and is not relevant to the test for balance and proprioception described in the scenario.

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