A nurse is assessing the reflexes of a client who has an unrepaired femur fracture and has suddenly become stuporous. For which of the following findings should the nurse identify that the client exhibits Babinski's sign?
Dorsiflexion of the great toe
Pronation of the arms
Pinpoint pupils
Jerking contractions of the head and neck
The Correct Answer is A
Choice A reason:
Babinski's sign is a neurological reflex that's tested by stroking the sole of the foot. A positive Babinski's sign, which is normal in infants but abnormal in adults, is indicated by dorsiflexion of the great toe (the toe points up) while the other toes fan out. This reflex suggests dysfunction of the corticospinal tract, which may be due to various neurological conditions. In the context of a stuporous patient with an unrepaired femur fracture, a positive Babinski's sign could indicate an acute neurological change possibly related to the injury or a secondary complication such as a fat embolism syndrome, which can occur after fractures and may affect the brain.
Choice B reason:
Pronation of the arms is not associated with Babinski's sign. Pronation is a rotational movement where the hand and upper arm are turned inwards. While arm movements are part of the neurological examination, they do not constitute a response to the plantar reflex test used to elicit Babinski's sign.
Choice C reason:
Pinpoint pupils may indicate opioid overdose or damage to the pons due to various causes, but they are not a component of Babinski's sign. Pupil size and reaction to light are important in neurological assessments, but they are separate from the reflexes tested by the Babinski sign.
Choice D reason:
Jerking contractions of the head and neck are not related to Babinski's sign. These could be indicative of seizure activity or other neurological disorders but are not a response to the plantar reflex test.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Morphine is an opioid analgesic that can cause a decrease in gastrointestinal motility, leading to constipation and exacerbation of paralytic ileus, a condition where there is a cessation of peristalsis in the intestine. In the case of paralytic ileus, the intestinal contents cannot move, which can lead to bowel distention, pain, and further complications. Therefore, morphine is contraindicated in clients with paralytic ileus due to the risk of worsening the condition..
Choice B reason:
While morphine can suppress cough and provide some relief in respiratory conditions, it is not contraindicated in bronchitis pleurisy unless respiratory depression is present. However, caution is advised as morphine can cause respiratory depression and should be used carefully in patients with underlying respiratory disorders.
Choice C reason:
Morphine is often used in the management of acute myocardial infarction (MI) to relieve chest pain, reduce anxiety, and decrease the workload on the heart by lowering blood pressure and heart rate. It is not contraindicated in MI; in fact, it can be beneficial in managing the symptoms associated with MI.
Choice D reason:
Postoperative pain management following hip arthroplasty often includes opioids like morphine. Morphine is not contraindicated in this situation and can be used to control postoperative pain, provided that the patient's respiratory function is closely monitored
Correct Answer is D
Explanation
Choice A reason:
Tennis may not be the best recommendation for someone with low back pain. The sport requires quick lateral movements, sudden stops, and starts, as well as repetitive twisting motions that can exacerbate back pain. While it provides good general exercise, the high-impact nature of tennis and the strain it puts on the back could potentially worsen the client's condition.
Choice B reason:
Canoeing involves repetitive rowing actions that can strain the lower back, especially if the individual does not use proper form. The seated position in a canoe may also put additional pressure on the lower back. Therefore, it might not be the most suitable activity for someone experiencing low back pain.
Choice C reason:
Rowing, similar to canoeing, can place stress on the lower back due to the repetitive motion and the need for strong engagement of the core muscles. If not performed with proper technique, rowing could lead to increased back pain and is not typically recommended for those with existing low back issues.
Choice D reason:
Swimming is often recommended for individuals with low back pain because it is a low-impact exercise that does not put additional stress on the spine. The buoyancy of the water supports the body, reducing the load on the back while allowing for a full range of motion. Swimming can help strengthen the back muscles and improve flexibility, making it a suitable activity for managing low back pain.
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