When assessing the left foot planter reflex of an adult client, the nurse observes an extension of the great toe and fanning of other toes. Which interpretation of this finding is accurate?

Normal reflex response for age.

Exaggerated reflex response.

Beginning meningeal irritation.

Pyramidal tract disease.

Answer and Explanation

The Correct Answer is D

A.   An extension of the great toe and fanning of other toes is known as a positive Babinski sign, which is abnormal in adults. This response is typically seen in infants but indicates neurological damage or dysfunction in adults.
B.   An exaggerated reflex would usually refer to hyperreflexia, but the Babinski sign specifically involves the abnormal extension of the toes, not just an exaggerated reflex. This response is more associated with neurological damage than simple exaggeration.
C.   The Babinski sign can sometimes be associated with central nervous system issues, including meningeal irritation. However, meningeal irritation often involves other symptoms such as neck stiffness, fever, and photophobia, which are not mentioned here.
D.   A positive Babinski sign is a classic indication of pyramidal tract disease, which affects the corticospinal tract. This type of neurological dysfunction can be seen in conditions like stroke, multiple sclerosis, or brain injury.

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Correct Answer is B

Explanation

A. Bronchitis may cause wheezing, but it typically presents with a productive cough and can be associated with fever, which this client does not have. The absence of a productive cough and the degree of difficulty breathing suggest another condition.
B. Asthma is the most likely diagnosis. The client’s wheezing, decreased tactile fremitus, prolonged expirations, and history of exercise-induced symptoms are consistent with an asthma exacerbation. Asthma often presents with wheezing and difficulty breathing, especially during or after physical exertion.
C. Pneumonia typically presents with fever, chills, productive cough, and localized lung findings, which are not present in this client. The lack of fever and the presence of wheezing make pneumonia unlikely.
D. Pneumothorax may cause dyspnea and decreased breath sounds, but the wheezing, prolonged expirations, and history of exertion suggest asthma as the primary concern. A pneumothorax would typically present with more abrupt onset and significant breath sounds asymmetry, which is not seen in this case.

A. Compare the range of motion of both legs. B. Ask if the client often feels weak or hungry. C. Measure the client's capillary glucose. D. Palpate the client's dorsalis pedis pulses.

Correct Answer is D

Explanation

A. While comparing the range of motion of both legs could be useful for detecting joint or muscle- related issues, it does not directly address the vascular concerns suggested by the shiny skin and absence of hair growth. These signs are more likely related to poor circulation, which requires different diagnostic approaches.
B. Asking about feelings of weakness or hunger may be more relevant to assessing the client’s blood glucose control, but it is not directly related to the symptoms of shiny skin and hair loss on the lower legs, which suggest peripheral vascular changes common in diabetes.
C. While measuring blood glucose levels is important in managing diabetes, it will not help to assess the vascular insufficiency suggested by the physical findings. However, managing blood glucose is crucial to preventing further complications.
D. Palpating the dorsalis pedis pulses is the most appropriate next step. Decreased or absent pulses in the feet and lower extremities are commonly associated with peripheral vascular disease, which is common in clients with diabetes due to poor circulation.

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When assessing the left foot planter reflex of an adult client, the nurse observes an extension of the great toe and fanning of other toes. Which interpretation of this finding is accurate?

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Correct Answer is B

Explanation

The nurse observes that the lower legs of a client with diabetes mellitus are shiny, and with no hair growth. To obtain additional data to support these findings, which assessment should the nurse perform?

Correct Answer is D

Explanation

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