A nurse is assisting in the care of a client.

Exhibits

Which of the following interventions should the nurse plan to implement? Select all that apply.

A. Drain the tub water before the client gets out. Draining the tub water before the client gets out is not a recommended practice. Instead, the nurse should ensure that the client has a safe way to exit the tub while the water is still in it, as the water can provide support and stability when getting out.
B. Add bath oil to the water after the client gets into the tub. Adding bath oil to the water can create a slippery surface, increasing the risk of falls and injury. It is best to avoid bath oils, especially for clients who may have mobility issues or are at risk for falls.
C. Allow the client to remain in the bath for 30 min. While soaking in a tub can be relaxing, staying in the bath for too long can increase the risk of overheating or dehydration. A shorter duration may be more appropriate, depending on the client's condition and safety.
D. Check on the client every 10 min during the bath. Checking on the client regularly during the bath is essential for ensuring their safety. This practice allows the nurse to monitor for any signs of distress, difficulty, or the need for assistance, providing reassurance and promoting the client's well-being.

A. "Sit on the edge of the bed while I tap your knee." The patellar reflex, also known as the knee-jerk reflex, is tested by tapping the patellar tendon while the client’s leg dangles. This does not assess the Babinski reflex, which involves stroking the sole of the foot.
B. "Lie down and I will stroke the bottom of your foot." The Babinski reflex is tested by stroking the lateral aspect of the sole from heel to toe. A normal response in adults is toe flexion, while dorsiflexion of the great toe with fanning of the others is abnormal and indicates neurological dysfunction.
C. "Place your foot in my hand and I will tap the back of your heel." This describes testing for the Achilles tendon reflex, which assesses the function of the S1 spinal nerve. The Babinski reflex requires a stroking motion along the foot’s sole rather than tapping the heel.
D. "Relax your arm across your chest and I will test your elbow extension." This describes testing the triceps reflex, which assesses the function of the C6-C7 nerve roots. The Babinski reflex is specific to neurological assessment of the lower extremities.