The nurse documents an abnormal finding from the Babinski reflex as a (the):
toes turning up and spreading
downward curl of the toes
pain in the big toe
big toe bending upward
The Correct Answer is A
A. Toes turning up and spreading:
This description corresponds to the abnormal finding in the Babinski reflex. In a positive Babinski sign, the big toe (hallux) dorsiflexes (turns upward) and the other toes fan out. This response is abnormal in adults but normal in infants up to a certain age.
B. Downward curl of the toes:
This response is typical of the normal plantar reflex, where the toes curl downward (plantar flexion) in response to stimulation of the sole of the foot. It is not indicative of the Babinski reflex.
C. Pain in the big toe:
Pain in the big toe is not a characteristic finding of the Babinski reflex. The Babinski sign is assessed by observing the movement pattern of the toes in response to stimulation, rather than eliciting pain.
D. Big toe bending upward:
The big toe bending upward, or dorsiflexion of the big toe, is a specific component of the positive Babinski sign. However, it is typically accompanied by spreading of the other toes, which is the hallmark feature of the Babinski reflex.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["10"]
Explanation
To calculate the dose of valproic acid oral solution, the nurse should use the following formula:
Dose (mL) = Ordered dose (mg) / Concentration (mg/mL) x Volume (mL)
Plugging in the values from the question, we get:
Dose (mL) = 500 mg / (250 mg / 5 mL) x 5 mL
Simplifying, we get:
Dose (mL) = 500 mg / 50 mg x 5 mL
Dose (mL) = 10 mL
Therefore, the nurse should administer 10 of valproic acid oral solution to the patient.
Correct Answer is C
Explanation
A. "I will notify my provider before taking any other medications."
This statement demonstrates understanding of the importance of consulting the provider before taking any other medications. It is correct because phenytoin may interact with other drugs, so notifying the provider is essential to avoid potential interactions.
B. "I have made an appointment to see my dentist next week."
This statement indicates that the client understands the importance of dental care while taking phenytoin. Phenytoin can cause gum overgrowth (gingival hyperplasia), so regular dental check-ups are recommended to monitor oral health. This statement is correct.
C. "I will take this medication with meals."
This statement suggests that the client plans to take phenytoin with meals. However, phenytoin should generally be taken on an empty stomach to enhance absorption, unless gastrointestinal upset occurs. Therefore, this statement indicates a need for further teaching.
D. "I'll be glad when my seizures stop so I can quit taking this medicine."
This statement reflects a misconception about the management of epilepsy. Phenytoin is typically used as a long-term treatment to prevent seizures, not as a short-term solution to stop seizures. Therefore, this statement indicates a need for further education about the chronic nature of epilepsy and the need for ongoing medication adherence.
E. “I’ll take this medication before meals.”
This statement correctly indicates the timing of phenytoin administration before meals. Taking phenytoin before meals helps enhance absorption and minimize the risk of gastrointestinal side effects. Therefore, this statement is correct.
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