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 D
Explanation
Explanation
D. Muscle cramps
Hyponatremia is a condition characterized by low levels of sodium in the blood. Sodium plays a crucial role in maintaining fluid balance and nerve and muscle function. When sodium levels are low, it can lead to imbalances in fluid levels and cause muscle cramps and weakness.
Constipation in (option A) is incorrect because it is more commonly associated with other conditions such as dehydration or electrolyte imbalances like hypercalcemia.
Blurred vision in (option B) is not a typical finding in hyponatremia. Visual disturbances may occur in severe cases, but they are not a consistent symptom.
Hypertension (high blood pressure) in (option C) is not typically associated with hyponatremia. In fact, hyponatremia can sometimes lead to low blood pressure (hypotension) due to the fluid imbalances it causes.
Therefore, the nurse should expect muscle cramps (option D) as a finding in a client with hyponatremia due to the disruption of fluid balance and its impact on muscle function.
Correct Answer is C
Explanation
a.Applying the restraint under the client's clothes: Restraints should be applied over the client's clothes to avoid direct skin contact and reduce the risk of skin irritation or injury.
b.Tying the restraint to the railing of the client's bed: Restraints should not be tied to bed rails or any other fixed objects. This can increase the risk of injury to the client and should be avoided.
c.Placing the client in a sitting position is appropriate when applying a belt restraint, as it helps prevent respiratory compromise and allows the client to maintain a safer and more comfortable posture.
d.A belt restraint should be placed around the client's waist, not across the chest, to avoid restricting breathing.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today