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.Coiling the tubing on the bed above the collection bag is incorrect because it can cause urine to flow back into the bladder, increasing the risk of infection and compromising the effectiveness of the drainage system. The tubing should be kept below the level of the bladder to ensure proper drainage.
B.Instructing the client to hold the drainage bag at waist height when ambulating is incorrect because the drainage bag should always be kept below the level of the bladder to prevent urine from flowing back into the bladder, which could lead to a urinary tract infection (UTI).
C.Securing the tubing with adhesive tape to the lower abdomen is correct because it helps prevent accidental pulling or tugging on the catheter, which could cause discomfort or dislodgement. Properly securing the tubing also helps maintain a continuous flow of urine and reduces the risk of infection.
D.Collecting a sterile specimen from the urinary drainage bag is incorrect because urine in the drainage bag is not considered sterile. If a sterile specimen is needed, it should be obtained by cleaning the catheter's sampling port with an antiseptic solution and withdrawing urine directly from the port using a sterile syringe.
Correct Answer is B
Explanation
- "Your health care surrogate will make decisions on your behalf if you are unable": This statement is correct. A health care surrogate, also known as a health care proxy or durable power of attorney for health care, is an individual designated by the client to make medical decisions on their behalf if they become unable to make decisions for themselves. It is important for the client to choose someone they trust and who understands their values and wishes.
- "You will need an attorney to appoint a health care surrogate": This statement is not necessarily true. While involving an attorney can be helpful, it is not always required to appoint a health care surrogate. In many jurisdictions, a legally valid health care surrogate designation can be made through a simple document or form provided by the hospital or a local government office. It is important to check the specific legal requirements in the client's jurisdiction.
- "You should appoint a family member as your health care surrogate": This statement is a subjective recommendation and may not be applicable to all individuals. The decision of whom to appoint as a health care surrogate should be based on the client's personal preferences and the individual's ability to make informed decisions according to the client's wishes. While a family member is often chosen, it is not a requirement, and the client may choose a close friend, partner, or anyone else they trust to fulfill this role.
- "Once you have completed a living will, it cannot be changed": This statement is incorrect. A living will, which is a type of advanced directive, can be changed or revoked at any time by the client as long as they are competent to do so. It is important for the client to review and update their living will periodically to ensure that it reflects their current wishes regarding medical care and treatment.
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