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:
The statement about eating a high fiber diet reducing the risk for developing skin cancer is misleading. While a high fiber diet has many health benefits, there is no direct evidence that it significantly reduces the risk of skin cancer. Skin cancer prevention primarily focuses on protecting the skin from excessive sun exposure and avoiding ultraviolet (UV) light sources.
Choice B reason:
Avoiding the use of tanning booths is correct advice. Tanning booths emit UV radiation, which can increase the risk of skin cancer, including melanoma, the deadliest form of skin cancer. The use of tanning beds is strongly discouraged by health professionals.
Choice C reason:
Using sunscreen even on cloudy days is also correct. UV rays can penetrate through clouds, and sun protection is necessary regardless of the weather to reduce the risk of skin cancer. Sunscreen should be applied to all exposed skin and reapplied regularly, especially after swimming or sweating.
Choice D reason:
Checking the skin monthly for any changes is an important part of skin cancer prevention. Early detection of changes in moles or new skin growths can lead to early diagnosis and treatment, which is crucial for a better prognosis. This practice should be encouraged as part of routine self-care.
Correct Answer is C
Explanation
Choice A reason:
Using chemotherapy instead of radiation may not be a viable option as the treatment plan is based on the type and stage of cancer. Chemotherapy can also affect fertility, so it is not a direct solution to the concern of infertility.
Choice B reason:
Fertility medications during treatment might help preserve fertility, but they do not address the direct impact of radiation on reproductive organs. Additionally, the use of such medications should be discussed with an oncologist and a fertility specialist.
Choice C reason:
Radiation shielding techniques involve using protective shields to limit radiation exposure to the reproductive organs. This can help reduce the risk of infertility caused by radiation, especially when the pelvic area is involved in the treatment.
Choice D reason:
Surgical interventions to remove the cancer may be part of the treatment plan, but they do not directly address the concern of radiation-induced infertility. Surgery can also result in infertility, depending on the organs involved and the extent of the procedure.
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