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."

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Correct. An incident report should be completed for any unintended event or situation that could have resulted or did result in harm to a patient. Administering the wrong dose of medication falls under this category.

B. Incorrect. The nursing care plan is a comprehensive outline of a patient's care needs and interventions and is not the appropriate place to document a medication error.

C. Incorrect. The provider's progress notes are meant to document the patient's condition, care, and progress, but they are not used to document medication errors.

D. Incorrect. The controlled substance inventory record is used to track the dispensing and administration of controlled substances, not to document medication errors.

A. "An incident report has been completed and sent to risk management." B. "Client stated, 'I lost my balance and fell when I got out of bed to go to the bathroom.'" C. "The client fell because the assistive personnel did not place nonskid slippers on the client." D. "The client does not appear to have any injuries resulting from the fall."

Correct Answer is B

Explanation

A. Incorrect. Mentioning the completion of an incident report is appropriate but not sufficient in explaining the incident.
B. Correct. Documenting the client's own statement about the fall is essential for accuracy and clarity in the medical record.
C. Incorrect. While footwear might contribute to falls, it's important to include the client's own account of the fall in the documentation.
D. Incorrect. While noting the absence of visible injuries is relevant, it's more important to document the circumstances leading to the fall.

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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?

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