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?

"Place your foot in my hand and I will tap the back of your heel."

"Lie down and I will stroke the bottom of your foot."

"Sit on the edge of the bed while I tap your knee."

"Relax your arm across your chest and I will test your elbow extension."

Answer and Explanation

The Correct Answer is B

The plantar Babinski reflex is assessed by stroking the sole of the foot from the heel towards the toes. A normal response is the flexion or curling of the toes. An abnormal response, known as a positive Babinski sign, is the extension and fanning out of the toes, which indicates an upper motor neuron lesion.

"Place your foot in my hand and I will tap the back of your heel": This instruction is more relevant to testing the Achilles tendon reflex, where the nurse taps the back of the heel to elicit a plantarflexion response.

"Sit on the edge of the bed while I tap your knee": This instruction is more relevant to testing the patellar reflex, also known as the knee-jerk reflex. The nurse taps the patellar tendon just below the kneecap to elicit a reflexive contraction of the quadriceps muscle.

"Relax your arm across your chest and I will test your elbow extension": This instruction is more relevant to testing the triceps reflex, where the nurse taps the triceps tendon to elicit a reflexive extension of the elbow.

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Correct Answer is C

Explanation

A.Wearing a face mask does not increase the risk of injury. In fact, it helps protect the client from infections, especially if they have concurrent neutropenia, which is common in conditions affecting the bone marrow.

B.Green, leafy vegetables are rich in vitamin K, which plays a role in clotting. However, they do not directly increase the risk of injury in a client with thrombocytopenia. While vitamin K affects clotting factors, thrombocytopenia primarily involves a deficiency of platelets, which are necessary for clot formation.

C.Clients with thrombocytopenia have a low platelet count, which increases their risk of bleeding. Using a firm-bristled toothbrush can cause gum trauma and bleeding, leading to complications such as prolonged bleeding or infection. A soft-bristled toothbrush or an alternative oral hygiene method (such as an oral swab) is recommended to minimize injury.

D.Adequate sleep does not increase the risk of injury. In fact, it may support overall health and immune function.

A. "I have a difficult time getting my child to eat green vegetables" B. "My child continually asks me the same questions" C. "My child still wets the bed at least two times per week" D. "I have noticed that my child is withdrawn since we switched day care providers

Correct Answer is D

Explanation

The priority is to address any significant changes in the child's behavior, such as withdrawal, as it may indicate emotional or psychological distress. Switching daycare providers can be a significant event for a young child, and it is essential to explore the reasons behind the child's withdrawal and address any potential underlying issues. The nurse should gather more information, assess the child's emotional well-being, and discuss any concerns or observations with the guardian. This will help identify appropriate interventions or support for the child's emotional adjustment.

While the other statements may also warrant attention, the potential emotional impact of the daycare provider change on the child's behavior and well-being takes priority in this case. The nurse should address the other concerns raised by the guardian during the assessment process, but the immediate focus should be on addressing the child's withdrawal and ensuring their emotional well-being.

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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 C

Explanation

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Correct Answer is D

Explanation

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