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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Hypertensive crisis is a severe increase in blood pressure that can lead to organ damage or other complications. Prompt assessment and intervention are necessary to prevent further escalation of blood pressure and potential complications.
While all the clients mentioned require attention, the client with elevated blood pressure and a headache poses a higher immediate risk. The nurse should assess the client's blood pressure, evaluate for signs of target organ damage, and initiate appropriate interventions, which may include administering antihypertensive medications as prescribed and monitoring closely for any changes in the client's condition.
The client who is postoperative and reports intermittent nausea can be assessed and managed after addressing the client with the elevated blood pressure and headache.
The client scheduled for surgery in 2 hours can be addressed according to the scheduled timeline.
Correct Answer is A
Explanation
Levothyroxine is a medication used to treat hypothyroidism, and monitoring the TSH levels helps determine the effectiveness of the medication.
Blood urea nitrogen (BUN) is a test used to assess kidney function and is not specifically related to thyroid function or levothyroxine therapy.
Prothrombin time (PT) is a test used to evaluate the clotting ability of the blood and is not directly related to thyroid function or levothyroxine therapy.
Arterial blood gases (ABGs) are used to assess oxygen and carbon dioxide levels in the blood and evaluate acid-base balance. ABGs are not specifically related to thyroid function or levothyroxine therapy.
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