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?
"Lie down and I will stroke the bottom of your foot."
"Sit on the edge of the bed while I tap your knee."
"Place your foot in my hand and I will tap the back of your heel."
"Relax your arm across your chest and I will test your elbow extension."
The Correct Answer is A
A. Correct. The plantar Babinski reflex is elicited by stroking the sole of the foot along the lateral aspect, from the heel to the ball of the foot. The nurse's instruction to the client is accurate.
B. Tapping the knee is related to the knee jerk reflex, not the Babinski reflex.
C. Tapping the back of the heel does not elicit the plantar Babinski reflex.
D. Testing elbow extension is unrelated to the Babinski reflex.
Nursing Test Bank
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Related Questions
Correct Answer is C
Explanation
A. Placing a pillow between the legs can actually provide support and comfort when lying on the back or non-operative side.
B. Gentle exercises are typically encouraged after hip arthroplasty to promote circulation and prevent complications.
C. Correct. Avoiding lying on the operative side helps prevent dislocation of the new hip joint.
D. Avoiding crossing the legs helps prevent hip joint stress, but avoiding lying on the operative side is more crucial.
Correct Answer is D
Explanation
A. Incorrect. The Patient Health questionnaire is used to assess depression severity.
B. Incorrect. The Mental Status Examination assesses cognitive function and psychiatric symptoms.
C. Incorrect. The Brief Psychiatric Rating Scale assesses psychiatric symptoms but not specifically tardive dyskinesia.
D. Correct. The Abnormal Involuntary Movement Scale (AIMS. is specifically designed to screen for and assess the severity of tardive dyskinesia, which is a movement disorder associated with antipsychotic medications.
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