Nurse Renner is about to perform Romberg’s test on Pierro. To ensure the latter’s safety, which intervention should nurse Renner implement?
A. Allowing the client to keep his eyes open.
B. Having the client hold on to furniture.
C. Letting the client spread his feet apart.
D. Standing close to provide support.
Correct Answer: D. Standing close to provide support.
During Romberg’s test, the client is asked to stand with feet together and eyes shut and still maintain balance with the minimum of sway. If the client loses his balance, the nurse standing close to provide support, such as having an arm close around his shoulder, can prevent a fall. Allowing the client to keep his eyes open, spread his feet apart, or hang on to a piece of furniture interferes with the proper execution of the test and yields invalid results.
Option A: The clinician asks the patient to first stand quietly with eyes open, and subsequently with eyes closed. The patient tries to maintain his balance. For safety, it is essential that the observer stand close to the patient to prevent potential injury if the patient were to fall. When the patient closes his eyes, he should not orient himself by light, sense or sound, as this could influence the test result and cause a false positive outcome.
Option B: In the Romberg test, the patient stands upright and asked to close his eyes. A loss of balance is interpreted as a positive Romberg sign. The Romberg test is positive when the patient is unable to maintain balance with their eyes closed. Losing balance can be defined as increased body sway, placing one foot in the direction of the fall, or even falling.
Option C: The patient is asked to remove his shoes and stand with his two feet together. The arms are held next to the body or crossed in front of the body. If the clinician observes that the patient is able to stand for long periods of time with the eyes closed, it is evident that the patient’s balance and proprioceptive deficits have decreased.