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. No sounds heard after listening for 3 to 5 minutes would be considered absent bowel sounds.
B. Correct. Hyperactive bowel sounds are louder and more frequent than normal and can indicate increased bowel motility. They can also be present in early bowel obstructions due to increased peristalsis.
C. Incorrect. Soft sounds at a rate of 1/min are within the range of normal bowel sounds.
D. Incorrect. Decreased motility would result in hypoactive bowel sounds, not hyperactive.

A. Recommend the client spend time alone in his room. B. Suggest the client exercise before going to bed. C. Offer the client low-protein snacks throughout the day. D. Encourage the client to use positive self-talk.

Correct Answer is D

Explanation

A. Social isolation can exacerbate depressive symptoms, so it's not recommended for the client to spend time alone in his room.
B. Exercise is generally beneficial for individuals with depression, but exercising before bedtime might interfere with sleep.
C. There's no evidence to support the direct relationship between low-protein snacks and managing major depressive disorder.
D. Correct. Encouraging the client to use positive self-talk can help counteract negative thought patterns that are often present in depression.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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