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. Blood urea nitrogen measures kidney function, is not related to thyroid health.
B. Arterial blood gases are used to assess oxygen and carbon dioxide levels in the blood, not related to thyroid health.
C. Prothrombin time is a test used to assess blood clotting, not related to thyroid health.
D. Correct. Monitoring thyroid stimulating hormone (TSH. levels is crucial for assessing the function of the thyroid gland and adjusting levothyroxine dosage as needed.
Correct Answer is C
Explanation
A. Incorrect. A urine output of 300 ml over 8 hours is within the expected range for a postoperative client and does not require immediate reporting.
B. Incorrect. Occasional small clots in the urine are common in the immediate postoperative period following a transurethral resection of the prostate and do not necessarily require immediate reporting.
C. Correct. Dark red urine can indicate bleeding and may be a sign of hemorrhage. This finding should be reported to the provider for further assessment and intervention.
D. Incorrect. A frequent urge to urinate is expected following a transurethral resection of the prostate, as irritation and swelling can occur in the immediate postoperative period.
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