A nurse is performing a neurological examination on a client who has a history of multiple sclerosis.

The nurse notices that the client has difficulty walking and maintaining balance.

Which of the following tests should the nurse use to assess the client’s coordination?

Romberg test

Heel-to-shin test

Finger-to-nose test

All of the above

Answer and Explanation

The Correct Answer is D

The nurse should use all of these tests to assess the client’s coordination, as they are part of a neurological exam for people with MS.

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Correct Answer is D

Explanation

This statement indicates an understanding of the teaching because it accurately describes the duration of the plantar grasp reflex in infants.

The plantar grasp reflex is when the toes flex and adduce when the sole of the foot is stimulated.It is usually present at or soon after birth and disappears between 6 and 12 months of age.

A. “The Moro reflex is also called the startle reflex because it occurs when the baby is startled by something.” B. “The Moro reflex helps the baby develop their sense of balance and coordination.” C. “The Moro reflex involves extending and flexing the arms and legs in response to a sudden movement.” D. “The Moro reflex can be used to assess the integrity of the baby’s nervous system.” E. “The Moro reflex can be triggered by changing the baby’s position or temperature.”

Correct Answer is ["A","C","D"]

Explanation

The Moro reflex, or startle reflex, is an involuntary response to a sudden loss of support or a loud noise that involves spreading and curling the arms and legs.

The Moro reflex involves three distinct components: spreading out the arms (abduction), pulling the arms in (adduction), and crying (usually). The baby may also extend and flex their legs.

The Moro reflex can be used to assess the integrity of the baby’s nervous system, as it reflects the development and function of the brain stem. Absence, asymmetry, or persistence of the Moro reflex may indicate neurological problems.

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A nurse is performing a neurological examination on a client who has a history of multiple sclerosis. The nurse notices that the client has difficulty walking and maintaining balance. Which of the following tests should the nurse use to assess the client’s coordination?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a group of parents about infant reflexes. Which of the following statements by a parent indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse is teaching a group of new parents about infant reflexes. Which of the following statements should the nurse include in the teaching? (Select all that apply.)

Correct Answer is ["A","C","D"]

Explanation

A nurse is observing a newborn’s reactions to different stimuli. The nurse touches the corner of the newborn’s mouth with a finger and sees that the newborn turns her head toward that side and starts to suck. The nurse recognizes this as:

A nurse is performing a routine assessment on a newborn. The nurse strokes the cheek of the newborn and notes that the newborn turns toward that side and opens his mouth. The nurse documents this finding as which of the following?

A nurse is evaluating an infant’s neuromuscular development by testing different reflexes. The nurse strokes the outer edge of the sole of the infant’s foot up toward the toes and observes that the infant’s toes fan upward and out. The nurse documents this as:

A nurse is performing a neurological assessment on a 4-month-old infant. The nurse gently drops the infant’s head backward while supporting the body. The nurse expects to see which of the following responses as part of a normal reflex?

A nurse is observing an infant who is lying on his back. The nurse notices that when the infant’s head is turned to the right, his right arm and leg extend, while his left arm and leg flex. The nurse recognizes this as which of the following reflexes?

A nurse is performing a neurological assessment on a newborn. Which of the following reflexes should disappear by 8 months of age? (Select all that apply.)

A nurse is performing a routine check-up on a 2-month-old infant. The nurse gently drops the infant from one hand to the other and observes that the infant’s arms and legs symmetrically extend, then abduct while fingers spread to form a C-shape. The nurse identifies this as:

A nurse is evaluating a 3-month-old baby for developmental milestones. Which of the following findings should the nurse report to the provider as a possible concern?

A nurse is performing a neurological examination on a client who has a history of multiple sclerosis.

The nurse notices that the client has difficulty walking and maintaining balance.

Which of the following tests should the nurse use to assess the client’s coordination?