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 ["B","C","E"]

Explanation

B: A repeat Mantoux test is commonly performed to monitor the effectiveness of tuberculosis treatment. It's important for the client to understand the need for follow-up testing.
C: Interactions between tuberculosis medications and other medications can occur. The client's understanding of the importance of notifying the provider about new medications helps ensure their safety and treatment effectiveness.
E: Tuberculosis treatment typically involves a combination of medications taken for a specific duration. Understanding the duration of treatment is important for the client's compliance and successful outcome.

A. Apply an ice pack to the affected extremity for 20 min every 2 hr. B. Administer aspirin for pain. C. Massage the affected extremity every 4 hr. D. Initiate bed rest.

Correct Answer is D

Explanation

A. Incorrect. Applying an ice pack to the affected extremity is not recommended for a client with deep vein thrombosis, as it could potentially exacerbate the condition by promoting vasoconstriction.
B. Correct. Administering aspirin for pain relief is an appropriate action for a client with deep vein thrombosis. Aspirin has anti-inflammatory and analgesic properties and can help manage pain associated with thrombosis.
C. Incorrect. Massaging the affected extremity is contraindicated for a client with deep vein thrombosis, as it can dislodge the clot and pose a risk of embolization.
D. Incorrect. Initiating bed rest is not recommended for a client with deep vein thrombosis.
Encouraging early ambulation and mobilization can help prevent complications such as thrombus extension and pulmonary embolism.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","C","E"]

Explanation

A nurse is caring for a client who is 12 hr postpartum and has deep vein thrombosis of the left leg. The client is receiving anticoagulant therapy. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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