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:
Nausea and vomiting are common symptoms of peritonitis, which can occur in clients receiving peritoneal dialysis. These symptoms result from the irritation and inflammation of the peritoneum, the membrane lining the abdominal cavity.
Choice B reason:
Hyperactive bowel sounds are not typically associated with peritonitis. In fact, bowel sounds may be diminished or absent due to the inflammatory process and potential ileus associated with peritonitis.
Choice C reason:
Bradycardia, or a slower than normal heart rate, is not a common manifestation of peritonitis. Peritonitis can cause tachycardia, an increased heart rate, as the body responds to inflammation and infection.
Choice D reason:
Increased urinary output is not a manifestation of peritonitis. Peritoneal dialysis involves the peritoneal cavity and not the urinary system directly. Peritonitis may actually lead to decreased urine output if the infection causes systemic effects.
Correct Answer is D
Explanation
Choice A reason:
Telling a client that they will be at an increased risk of breast cancer due to fibrocystic breast changes would be incorrect. Fibrocystic breast changes are not directly linked to an increased risk of breast cancer. While the presence of complex fibrocystic changes may slightly elevate the risk, fibrocystic breasts themselves are a common and benign condition.
Choice B reason:
It is not accurate to say that the manifestations of fibrocystic breasts often get worse after menopause. In fact, fibrocystic changes are related to hormone levels, and most women experience relief from these symptoms after menopause when hormone levels decline.
Choice C reason:
Stating that menopause won't have any effect on the manifestations is also incorrect. Menopause typically leads to a decrease in hormone levels, which are associated with fibrocystic breast changes. Therefore, most women see an improvement in their symptoms after menopause.
Choice D reason:
The most appropriate response is that the manifestations usually go away after menopause. Fibrocystic breast changes are linked to hormonal fluctuations, and after menopause, when these fluctuations cease, the symptoms of fibrocystic breasts typically resolve.
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