Exam Guide

Assessing Balance: Romberg and Heel-to-Toe Walking

Health Assessment & Documentation · Question from the ATI PN Fundamentals 2023 Proctored Exam study set

Question: A nurse is assessing a client's balance. Which actions should the nurse take? (Select all that apply)

Correct answers:

  • Perform the Romberg test
  • Have the client perform heel-to-toe walking

Why this is the answer

The Romberg test evaluates static balance and proprioception with the eyes closed, while tandem (heel-to-toe) walking evaluates dynamic balance and gait coordination.

The bigger concept

Balance and coordination are part of the neurologic and musculoskeletal data collection. The Romberg test (feet together, arms at sides, eyes closed for 20–30 seconds) checks proprioception and static balance; a positive test is swaying or losing balance. Tandem heel-to-toe walking checks dynamic balance and cerebellar function. Stand close enough to catch the client during both tests — the assessment itself is a fall risk.

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