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

Orthostatic hypotension, which is a sudden drop in blood pressure upon standing, can be a side effect of enalapril and may lead to syncope. Instructing the client to rise slowly from a sitting to a standing position helps minimize the risk of a sudden drop in blood pressure and decreases the chances of syncope occurring.

Decreasing fluid intake is not likely to be the cause of syncope related to enalapril. It is important for clients to maintain adequate hydration, especially if they are experiencing side effects such as orthostatic hypotension.

While a low pulse rate may indicate bradycardia, it is not the primary concern in this situation. Orthostatic hypotension leading to syncope is the main issue, and the client should be instructed to rise slowly to prevent it.

While enalapril is an angiotensin-converting enzyme (ACE) inhibitor that can increase potassium levels in the blood, it is not directly related to syncope. Dietary changes should be made under the guidance of a healthcare provider based on individual needs and blood test results.

A. Hospice care B. Long-term care facility C. Adult day care facility D. Community senior center

Correct Answer is C

Explanation

explanation:

Adult day care facilities provide a safe and supervised environment for older adults during the day, while their family members or caregivers are at work or unable to be present. These facilities offer various activities, social interactions, and personal care services to support the needs of individuals with dementia and other conditions. Attending an adult day care facility canalso give the client an opportunity to engage with others and maintain cognitive and physical stimulation.

A- Hospice care is generally recommended for individuals with terminal illnesses who are nearing the end of life. It focuses on providing comfort and support to the patient and family during the end-of-life journey.

B- Long-term care facilities may be appropriate for some individuals with advanced dementia who require round-the-clock care and supervision. However, in this scenario, the client's adult child is present and working full time, suggesting that the family intends to provide care at home as much as possible.

D- Community senior centers may offer various activities and programs for older adults, but they may not provide the level of supervision and care required for an individual with early onset dementia during the day, especially if their family member is at work.

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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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Explanation

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Explanation

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