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.
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Related Questions
Correct Answer is D
Explanation
A. Incorrect. The cause of death is an important piece of information but is typically included in the official death certificate rather than in routine postmortem documentation.
B. Incorrect. While vital signs are important during the client's care, the last set of vital signs is not usually a primary focus of postmortem documentation.
C. Incorrect. Advance directives are relevant to the client's care during life but are not typically included in postmortem documentation.
D. Correct. Documentation of the location of the identification tag on the client's body is important for accurate identification and tracking during the postmortem process.
Correct Answer is C
Explanation
Answer is:Drain the tub water before the client gets out.
Explanation: This is the correct answer because it reduces the risk of slipping and falling for the client, especially if they have limited mobility or balance problems. The other options are incorrect because:
- Checking on the client every 10 min during the bath is not enough to ensure their safety and comfort.The nurse should check on them more frequently, such as every 5 to 10 minutes, depending on their needs and preferences.
- Adding bath oil to the water after the client gets into the tub is not a good idea because it can make the water slippery and increase the risk of falling.The nurse should add bath oil to the water before the client gets into the tub, or use a non-slip mat or shower chair.
- Allowing the client to remain in the bath for 30 min is too long and can cause dehydration, hypothermia, or skin irritation.The nurse should instruct the client to remain in the tub for no longer than 20 min, unless otherwise ordered by a physician.
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