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 D

Explanation

A. Incorrect. Instructing the client to take a brisk walk might exacerbate their symptoms.
B. Incorrect. Checking the client's temperature is not indicated based on the reported symptoms.
C. Incorrect. Providing orange juice might help with low blood sugar but doesn't directly address the reported symptoms.
D. Correct. Positioning the client on their left side can improve blood flow to the heart and uterus, alleviating symptoms of dizziness and racing heart that can occur due to pressure on the vena cava when lying flat on the back.

A. Remove the tape by pulling from the center of the dressing. B. Clean the wound from the center to the outer edges. C. Moisten the dressing before removal. D. Wear sterile gloves to remove the dressing.

Correct Answer is B

Explanation

A. Incorrect. When removing tape, it is best to pull in the direction of hair growth to minimize skin trauma.
B. Correct. When performing a wet-to-dry dressing change, the wound should be cleaned from the center to the outer edges to prevent introducing contaminants into the wound.
C. Incorrect. Wet-to-dry dressings are typically used to debride wounds by allowing the moist dressing to dry and adhere to wound debris. Moistening the dressing before removal can disrupt this process.
D. Incorrect. Sterile gloves are not typically necessary for performing a wet-to-dry dressing change, as it is a clean technique.

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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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