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?
"Place your foot in my hand and I will tap the back of your heel."
"Lie down and I will stroke the bottom of your foot."
"Sit on the edge of the bed while I tap your knee."
"Relax your arm across your chest and I will test your elbow extension."
The Correct Answer is B
The plantar Babinski reflex is assessed by stroking the sole of the foot from the heel towards the toes. A normal response is the flexion or curling of the toes. An abnormal response, known as a positive Babinski sign, is the extension and fanning out of the toes, which indicates an upper motor neuron lesion.
"Place your foot in my hand and I will tap the back of your heel": This instruction is more relevant to testing the Achilles tendon reflex, where the nurse taps the back of the heel to elicit a plantarflexion response.
"Sit on the edge of the bed while I tap your knee": This instruction is more relevant to testing the patellar reflex, also known as the knee-jerk reflex. The nurse taps the patellar tendon just below the kneecap to elicit a reflexive contraction of the quadriceps muscle.
"Relax your arm across your chest and I will test your elbow extension": This instruction is more relevant to testing the triceps reflex, where the nurse taps the triceps tendon to elicit a reflexive extension of the elbow.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Explanation:
A nasal cannula is a device used to deliver supplemental oxygen to a client. It consists of two prongs that are inserted into the client's nostrils and connected to an oxygen source. The nasal cannula is commonly used for low-flow oxygen delivery at a rate of 1 to 2 liters per minute (L/min).
The other options mentioned are not necessary supplies for the client upon discharge:
B- Petroleum jelly is not directly related to oxygen therapy and is not a required supply for the client. It is a common topical ointment used for various purposes such as moisturizing the skin or protecting the lips, but it is not specifically needed for oxygen administration.
C- An oxygen mask is an alternative device for oxygen delivery but is not typically used at a flow rate of 1 to 2 L/min. Oxygen masks are usually employed for higher flow rates or in specific clinical situations that require a different oxygen delivery method.
D- A reservoir bag is a component of some oxygen delivery systems, such as a non-rebreather mask or a bag-valve-mask device. However, at a flow rate of 1 to 2 L/min, a reservoir bag is not typically used. It is more commonly utilized in situations where higher oxygen concentrations or higher flow rates are required.
Correct Answer is C
Explanation
When removing the dressing and cleaning the wound, it is important to start from the center of the wound and work towards the outer edges. This technique helps prevent contamination of the wound by minimizing the risk of dragging bacteria or debris from the surrounding skin into the wound.
The other options listed are not recommended for this specific procedure:
When removing the tape, it is generally recommended to pull it parallel to the skin surface rather than pulling from the center of the dressing. This technique reduces the risk of causing trauma or disrupting the wound.
While it is important to maintain aseptic technique during dressing changes, wearing sterile gloves is not necessary for a wet-to-dry dressing change. Clean, non-sterile gloves are typically sufficient for this procedure, as the dressing material itself is not sterile.
In a wet-to-dry dressing change, the dressing is typically applied moist and allowed to dry over time. Therefore, moistening the dressing before removal is not necessary. The primary goal is to remove the dry dressing, which may adhere to the wound bed, and then clean the wound before applying a fresh dressing.
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