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 C
Explanation
A. Incorrect. In the event of an outdoor chemical disaster, individuals should stay indoors and take shelter rather than exiting the home.
B. Incorrect. Opening the dampers of fireplaces could allow outdoor contaminants to enter the home.
C. Correct. Covering heat registers with plastic and tape can help prevent outdoor chemicals from entering the home through the ventilation system.
D. Incorrect. Turning on ceiling fans and air conditioners could potentially bring outdoor contaminants indoors through the ventilation system.
Correct Answer is B
Explanation
The correct answer is choiceb. Support the client’s decision to stop the treatment.
Choice A rationale:
While discussing the decision with family can be important, the nurse’s primary responsibility is to respect and support the client’s autonomy and decision-making capacity. Encouraging the client to discuss with family is secondary to supporting their decision.
Choice B rationale:
Supporting the client’s decision to stop treatment respects their autonomy and right to make decisions about their own care.This is a fundamental principle in nursing ethics and patient-centered care.
Choice C rationale:
Discussing alternative treatment methods may be appropriate in some contexts, but in this case, the client has already made a decision to stop dialysis. The nurse should focus on supporting this decision rather than suggesting alternatives.
Choice D rationale:
Asking the facility chaplain to visit the client can be supportive, but it should not be the nurse’s primary action. The nurse should first support the client’s decision and then offer additional support services as needed.
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