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
Phenytoin is known to cause gingival hyperplasia, which is characterized by swollen and enlarged gums. This side effect is more common in long-term use and may require dental care and regular oral hygiene practices.
Phenytoin is known to be associated with an increased risk of birth defects in babies born to women taking the medication during pregnancy. It is important for women of childbearing age to discuss the risks and benefits of phenytoin with their healthcare provider and use effective contraception to avoid pregnancy while taking the medication.
Phenytoin can affect liver function, so regular monitoring of liver enzymes and blood levels of the medication is necessary. The frequency of blood work may vary depending on the individual's specific situation, so it is important to follow the healthcare provider's instructions. It is not advisable to skip a dose of phenytoin without consulting a healthcare provider.
Abruptly stopping or missing doses of antiepileptic medications can lead to breakthrough seizures or other complications. Any changes in the medication regimen should be discussed with the healthcare provider.
Correct Answer is A
Explanation
A- Apply a skin barrier protectant to the site: Using a skin barrier protectant helps shield the peristomal skin from irritation and breakdown caused by gastric contents and formula leakage.
B- Apply water-soluble lubricant to the site: Similarly, applying a water-soluble lubricant to the site is not a routine step in gastrostomy tube site care. Lubricants are typically used during the insertion of the tube or for intermittent tube feedings, but not for routine site care.
C- Tape the tube to the child's cheek: Taping the tube to the child's cheek is not necessary for routine site care. The tube should be secured using a dressing or device designed for gastrostomy tube stabilization, rather than taping it to the cheek.
D.Attaching an extension tube is related to administering feedings or medications rather than the maintenance and care of the gastrostomy site. Site care focuses on protecting the skin and ensuring cleanliness around the tube insertion area.
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