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
A.While it's important to document visitors and support persons, this information may not be considered crucial for the change-of-shift report unless it directly impacts the client's care or well-being.
B. The client received the prescribed antibiotic every 8 hours: This is important information, but it is typically documented in the medication administration record (MAR) and does not need to be included in the verbal report unless there were issues or changes related to the medication.
C. The client reports pain is reduced when positioned on his side: This is significant information as it informs the incoming nurse about the client's preferred position for pain management. It helps guide the nurse in providing comfort measures and appropriate positioning for the client. The client's mother died 4 years ago from breast cancer: This information may not be considered vital for the change-of-shift report unless it directly impacts the client's current condition or ongoing care.
D. The client's mother died 4 years ago from breast cancer: This information may not be considered vital for the change-of-shift report unless it directly impacts the client's current condition or ongoing care.
Correct Answer is D
Explanation
Pelvic rocking exercises can help relieve lower back pain during pregnancy. The client can perform this exercise by getting on their hands and knees, keeping their back straight, and gently rocking their pelvis back and forth. This helps to stretch and strengthen the muscles in the lower back and pelvis.
Sit in a hot tub for 30 min every evening: Hot tubs and hot baths are not recommended during pregnancy as they can raise the body temperature too high, which can be harmful to the developing fetus.
Raise chairs to keep knees lower than hips: This recommendation is more appropriate for promoting good posture and reducing strain on the back, but it may not specifically address lower back pain.
Use the arms to pick up heavy items: It is important to avoid heavy lifting during pregnancy as it can strain the back and increase the risk of injury. It is recommended to use proper lifting techniques, such as bending the knees and using the leg muscles rather than the back muscles, to lift objects.
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