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."

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Incorrect. Maintaining abduction of the residual limb with a pillow is not relevant to promoting mobility and independence for a client with an above-the-knee amputation.
B. Correct. Encouraging the client to use the overbed trapeze can help the client perform upper body movements and reposition independently, which is essential for maintaining mobility.
C. Incorrect. Avoiding a prone position may not be necessary for the client after an above-the-knee amputation and does not directly contribute to mobility and independence.
D. Incorrect. Keeping a loose, absorbent dressing over the surgical site is important for wound care, but it does not directly promote mobility and independence.

A. Apply the restraint under the client's clothes. B. Place the client in a sitting position. C. Tie the restraint to the railing of the client's bed. D. Ensure the restraint is placed across the client's chest.

Correct Answer is B

Explanation

A.Restraints should never be applied directly on the skin or under clothing, as this can cause irritation, pressure injuries, and make it difficult for the nurse to assess skin integrity. Restraints should be placed over the client's clothing to reduce friction and protect the skin.

B.Positioning the client in a sitting or semi-Fowler's position is preferred as it promotes comfort, minimizes the risk of aspiration, and allows the nurse to monitor the client's airway, breathing, and circulation more effectively. Lying flat can increase discomfort and respiratory difficulty, especially if the client is aggressive or agitated.

C.Restraints should never be tied to movable parts, like bed rails, as this could result in injury if the bed rail is moved up or down. Restraints should be tied to a non-movable part of the bed frame to ensure stability and prevent accidental tightening or loosening that could harm the client.

D.A belt restraint should be placed across the client’s waist or hips, not the chest, as a chest restraint can impede respiratory function, especially in an aggressive client who may be physically exerting themselves. The restraint should secure the client’s lower body to prevent them from standing or moving excessively, while still allowing safe breathing and circulation.

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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?

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