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 D

Explanation

Range-of-motion exercises are within the scope of practice for an AP and do not require specialized nursing knowledge or assessment skills. The AP can assist the client in performing these exercises to promote circulation, maintain joint mobility, and prevent complications associated with immobilization.

Determining the circulation status of the affected extremities, evaluating the need for restraints, and providing education to the client's family about the purpose of restraints require nursing assessment, critical thinking, and communication skills. These tasks should be performed by a licensed nurse who can make clinical judgments and ensure the safety and well-being of the client.

A. Obtain a complete blood count. B. Prepare client for insertion of 18-gauge peripheral IV prior to surgery. C. Administer Rh, D immune globulin prior to surgery. D. Explain the surgical procedure to the client. E. Verify consent form is signed by the client. F. Assist with administration of AB positive blood products if needed. G. Remind client to be NPO prior to surgery.

Correct Answer is ["A","B","C","E","G"]

Explanation

Based on the given information, the nurse should take the following actions in preparation for surgery:

Obtain a complete blood count: This is important to assess the client's hemoglobin, hematocrit, and other blood parameters before surgery.
Prepare the client for insertion of an 18-gauge peripheral IV prior to surgery: Adequate IV access is necessary for the administration of fluids and medications during and after surgery.
Administer Rh, D immune globulin prior to surgery: This action is indicated if the client is Rh-negative and there is a possibility of fetal-maternal blood mixing during the termination of pregnancy. Rh, D immune globulin is given to prevent sensitization to Rh-positive blood.
Verify consent form is signed by the client: Ensuring that the client has provided informed consent is essential before proceeding with any surgical intervention.
Remind the client to be NPO (nothing by mouth) prior to surgery: It is important for the client to have an empty stomach to reduce the risk of aspiration during anesthesia.

The following actions are not indicated based on the given information:

Explaining the surgical procedure to the client: Although it is important for the client to have an understanding of the procedure, this is typically done by the surgeon rather than the nurse.
Assisting with administration of AB positive blood products if needed: There is no indication of the need for blood products based on the information provided. Blood product administration would be determined based on the client's specific condition and surgical requirements.

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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

A nurse at a long-term care facility is reviewing the plan of care for a client who has a prescription for mitten restraints. Which of the following tasks should the nurse assign to an assistive personnel?

Correct Answer is D

Explanation

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Correct Answer is ["A","B","C","E","G"]

Explanation

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