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 B

Explanation

B. Make a schedule for daily task.

Creating a schedule of daily tasks can provide structure and routine for individuals with Alzheimer's disease. This helps reduce confusion and frustration by providing a sense of familiarity and predictability. The schedule should be displayed in a visible location and include activities such as meals, personal care, medication administration, and any recreational or therapeutic activities. Following the schedule can help the client feel more oriented and decrease their frustration levels.

Limiting the use of familiar objects in (option A) should not be included because it may further increase frustration and disorientation. Familiar objects can provide comfort and a sense of security for individuals with Alzheimer's disease.

Asking questions that require more than one answer in (option C) should not be included because it can be overwhelming and confusing for someone with Alzheimer's disease. It is best to ask simple, straightforward questions to facilitate communication and comprehension.

Having several family members visit daily in (option D) should not be included because it may cause agitation and overstimulation for the client. It is important to maintain a calm and predictable environment, limiting the number of visitors and ensuring they are familiar to the client.
Therefore, the most appropriate intervention for the nurse to include is making a schedule of daily tasks (option B).

A. Cantaloupe B. Sweet potato C. Orange juice D. Baked chicken breast

Correct Answer is D

Explanation

Potassium is an essential electrolyte that plays a crucial role in various bodily functions. However, for individuals with an electrolyte imbalance, it is often necessary to limit their potassium intake. Among the options provided, baked chicken breast is the lowest in potassium. Cantaloupe is relatively high in potassium. A cup of diced cantaloupe contains about 430 mg of potassium.

Sweet potatoes are known for their high potassium content. A medium-sized sweet potato with skin contains about 542 mg of potassium.

Orange juice also contains a moderate amount of potassium. An 8-ounce serving of orange juice typically contains around 450 mg of potassium.

Chicken breast is naturally low in potassium compared to fruits and vegetables. It contains about 260 mg of potassium per 4-ounce serving.

Therefore, among the given options, the baked chicken breast is the lowest in potassium and would be the most suitable choice for a client with an electrolyte imbalance requiring a low-potassium diet.

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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?

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