A nurse is assisting in the care of a client who is malnourished and states, ‘’I refuse to eat right now. It goes against my beliefs.’’ Which of the following responses should nurse make?

A) "Relax your arm across your chest and I will test your elbow extension.": This instruction is not relevant to testing the plantar Babinski reflex. The Babinski reflex involves the lower extremities, specifically the foot, not the arm or elbow. This instruction pertains to testing the upper extremity and is incorrect for this context.

B) "Place your foot in my hand and I will tap the back of your heel.": This is not the correct method for testing the plantar Babinski reflex. The Babinski reflex is tested by stroking the sole of the foot, not by tapping the back of the heel. The test is designed to elicit a response from the foot, not by applying pressure to the heel.

C) "Sit on the edge of the bed while I tap your knee.": This instruction relates to testing the patellar reflex (knee jerk), not the plantar Babinski reflex. The Babinski reflex involves stroking the bottom of the foot, not tapping the knee, so this is not appropriate for the test in question.

D) "Lie down and I will stroke the bottom of your foot.": This is the correct instruction for testing the plantar Babinski reflex. The client should be in a comfortable position, typically lying down, and the nurse should gently stroke the sole of the foot from the heel to the toes to assess the reflex. A normal response in adults is for the toes to curl downward, while an abnormal response (Babinski sign) would be the extension of the big toe and fanning of the other toes.

A) Instruct another nurse to record the prescription in the medical record:
The nurse receiving a telephone prescription is responsible for ensuring the prescription is recorded correctly in the medical record. It is not appropriate to delegate this responsibility to another nurse. The nurse should personally document the prescription to ensure accuracy and clarity.

B) Withhold the medication until the provider signs the prescription:
The nurse should not withhold the medication solely based on the provider's signature. Telephone prescriptions are valid once they are received and documented accurately by the nurse. The prescription must be signed by the provider as soon as possible, but withholding medication is not warranted unless there are other concerns with the prescription.

C) Ask the provider to spell out the name of the medication:
When receiving a telephone prescription, the nurse should ask the provider to spell out the name of the medication to avoid errors. Medication names, especially those that sound similar, need to be communicated clearly to ensure correct medication administration. This action helps prevent misinterpretation or confusion, ensuring patient safety.

D) Record the date and time of the telephone prescription:
Recording the date and time of the telephone prescription is essential for accurate documentation and legal purposes. This step ensures that there is a clear record of when the prescription was given and that the provider’s order is traceable in the client’s medical record. It also assists in meeting legal and institutional documentation requirements.

E) Request that the provider confirm the read-back of the prescription:
The nurse should read back the prescription to the provider to confirm accuracy. This action is part of the "read-back" process, a safety measure used to verify that the prescription has been communicated correctly and understood by both the nurse and the provider. This step helps reduce the risk of medication errors.