When the nurse asks an older patient to stand with feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. How should the nurse document this finding?

Choice A reason: Homan sign tests for deep vein thrombosis, not balance. Swaying with eyes closed indicates a positive Romberg sign, so this is incorrect for the documented finding. Choice B reason: Lack of coordination is vague and not specific to the Romberg test, which assesses proprioception. Positive Romberg sign describes the sway, so this is incorrect for documentation. Choice C reason: A positive Romberg sign is documented when a patient sways or loses balance with eyes closed, indicating proprioceptive or cerebellar issues. This is the correct term for the finding. Choice D reason: Ataxia describes general movement, not the specific Romberg test outcome. Swaying in this context is a Romberg sign, so this is incorrect for the nurse’s documentation.