A nurse is preparing to test a client's plantar Babinski reflex. Which of the following Instructions should the nurse give to prepare the client for this test?
"Lie down and I will stroke the bottom of your foot."
"Sit on the edge of the bed while I tap your knee."
"Place your foot in my hand and I will tap the back of your heel."
"Relax your arm across your chest and I will test your elbow extension."
The Correct Answer is A
A. Correct. The plantar Babinski reflex is elicited by stroking the sole of the foot along the lateral aspect, from the heel to the ball of the foot. The nurse's instruction to the client is accurate.
B. Tapping the knee is related to the knee jerk reflex, not the Babinski reflex.
C. Tapping the back of the heel does not elicit the plantar Babinski reflex.
D. Testing elbow extension is unrelated to the Babinski reflex.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choiced. Route.
Choice A rationale:
The time of administration is typically specified in the prescription and does not usually require clarification unless there are specific concerns about timing with other medications or meals.
Choice B rationale:
The medication, erythromycin, is clearly specified in the prescription. There is no ambiguity about which medication is being prescribed.
Choice C rationale:
The dosage of 500 mg is clearly stated and is a standard dose for erythromycin. There is no need to clarify this unless there are specific patient concerns or conditions that might affect dosing.
Choice D rationale:
The route of administration (e.g., oral, intravenous) is crucial information that must be clarified if not specified.Erythromycin can be administered in multiple ways, and the effectiveness and side effects can vary depending on the route
Correct Answer is C
Explanation
A. Incorrect. Elevating the arm might help reduce edema, but the priority is to stop the infusion to prevent further infiltration.
B. Incorrect. While documenting the infiltration is important, immediate action should be taken to stop the infusion to prevent further complications.
C. Correct. The nurse's first action should be to stop the infusion to prevent the continuation of fluid infiltration and potential complications.
D. Incorrect. Applying a warm compress might help with comfort, but stopping the infusion is the priority to prevent further infiltration.
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