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 B
Explanation
Choice A reason:
Using an antibiotic ointment is not typically recommended as a preventive measure for skin integrity during radiation therapy. Antibiotic ointments are used to treat bacterial infections, and their use should be directed by a healthcare provider if an infection is present or there is skin breakdown.
Choice B reason:
It is important not to apply heat to the area of irradiation as heat can increase skin irritation and the risk of burns in the treated area. Patients undergoing radiation therapy are advised to avoid heat sources, including heating pads, hot water bottles, and direct sunlight, to prevent further damage to the skin.
Choice C reason:
Lubricating the skin with hypoallergenic lotion can help maintain skin integrity by keeping it moisturized. However, it is crucial to use lotions that are free of metals, alcohol, perfumes, and dyes, as these can react with radiation and cause skin irritation. Lotions should be applied after radiation therapy sessions and not immediately before treatment.
Choice D reason:
The instruction not to wash the area of irradiation is incorrect. It is essential to keep the skin clean to reduce the risk of infection. Patients should gently wash the irradiated area with lukewarm water and mild soap, and pat the area dry with a soft towel. They should avoid scrubbing or using harsh soaps that can irritate the skin.
Correct Answer is D
Explanation
Choice A reason:
Abdominal distention can be a sign of delayed return of peristalsis or ileus, especially when accompanied by other symptoms such as nausea, vomiting, or lack of bowel movement. It is not typically a sign that peristalsis is returning.
Choice B reason:
A request for a cup of tea and some toast may indicate that the client is feeling better and is hungry, which can be a good sign. However, it is not a definitive clinical indicator of the return of peristalsis. The desire to eat does not necessarily mean that the digestive system is ready to process food.
Choice C reason:
Hypoactive bowel sounds in two quadrants may indicate that peristalsis is present but weak. While this could be a sign that peristalsis is starting to return, it is not as strong an indicator as the passage of flatus or stool.
Choice D reason:
The passage of flatus is a clear sign that peristalsis is returning. It indicates that gas is moving through the intestines, which is a function of peristalsis. This is often one of the first signs that the gastrointestinal system is recovering after surgery.
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