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 C
Explanation
This response allows the nurse to express genuine interest in the client's perspective and opens up a dialogue to understand the client's concerns or reasons for refusing to learn how to self-administer insulin. It provides an opportunity for the client to express their fears, doubts, or any barriers they may have. By actively listening to the client, the nurse can better address their concerns and provide appropriate education and support tailored to their individual needs.
The other options may come across as confrontational, judgmental, or unhelpful in establishing a therapeutic relationship with the client. It is important for the nurse to approach the situation with empathy, respect, and a non-judgmental attitude to foster effective communication and promote the client's engagement in their own care.
Correct Answer is C
Explanation
Explanation:
Displacement is a defense mechanism in which an individual redirect their emotions or impulses from their original target to a less threatening or safer target. In this scenario, the client yells at the nurse when medication changes are prescribed by the provider. The client may be feeling angry or frustrated about the medication changes but is unable to express those emotions directly towards the provider. Instead, the client displaces those feelings onto the nurse, who may be seen as a safer or more accessible target. The yelling behavior directed at the nurse is a way for the client to release and express their emotions indirectly.
Let's briefly discuss the other defense mechanisms mentioned:
A- Conversion: Conversion involves the expression of psychological distress or conflict through physical symptoms or ailments. It is not applicable in this scenario since the client's behavior does not involve physical symptoms.
B- Splitting: Splitting is a defense mechanism characterized by a black-and-white thinking pattern, where individuals perceive others or situations as all good or all bad. It does not directly apply in this scenario as the client's behavior is not indicative of splitting.
D- Sublimation: Sublimation is a defense mechanism in which an individual channel their unacceptable or potentially harmful impulses into socially acceptable outlets, such as creative or productive activities. It is not evident in this scenario as the client's behavior does not involve transforming the emotions into a more positive or socially acceptable form.
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