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 ["B","C"]
Explanation
A. Not indicated and could lead to complications.
B. The client reports abdominal cramping and a small, hard, painful bowel movement. A sit bath can help provide relief and comfort to the perineal area, which can be beneficial after experiencing bowel discomfort.
C. The client reports pain and has had a small, hard, painful bowel movement. Encouraging oral fluid intake helps prevent dehydration and can soften the stool, making it easier to pass and reducing the risk of constipation.
D. Not necessary or appropriate without further assessment.
E. Not necessary and may not provide any additional benefit in this context.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"E"}
Explanation
Given the client's symptoms (productive cough, blood-tinged sputum, fatigue, night sweats, low-grade fever, weight loss, and recent travel to South Africa), there is a suspicion of tuberculosis (TB). The Mantoux test (a skin test for TB) and a chest X-ray are appropriate diagnostic tools to evaluate for TB.
A. a nasopharyngeal swab: This test is used to detect respiratory infections, but the client's symptoms and history do not specifically indicate the need for this test.
B. A pulmonary function test: While this test assesses lung function, it may not be the initial choice for evaluating the presented symptoms and history.
C. A chest x-ray
Rationale: Given the client's symptoms of cough, fatigue, night sweats, low-grade fever, and blood-tinged sputum, a chest x-ray is indicated to assess the condition of the lungs and potential underlying respiratory issues.
D. blood cultures
Rationale: The client's symptoms, including fever, could indicate an underlying infection. Blood cultures are used to identify potential bacterial or fungal infections in the bloodstream, but this is not likely for this patient
E. a Mantoux test
Rationale: The client's recent travel history, cough, and weight loss may prompt consideration of a tuberculosis (TB) infection. A Mantoux test is a common initial screening tool for TB exposure.
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