The nurse evaluates the Babinski reflex and strokes the sole of the patient's foot from the outer heel to the little toe. The patient was in an automobile accident and has a decreased level of consciousness. Which response indicates an abnormality in the cerebral cortex?

The foot remains in the same position prior to stroking the sole of the foot.

Great toe bends upward and smaller toes fan outward.

Great toe bends downward.

The opposite foot assumes the same position as the foot being stroked.

Answer and Explanation

The Correct Answer is B

Choice A reason: This is incorrect. The foot remaining in the same position prior to stroking the sole of the foot is a normal response in adults. It indicates that the spinal cord and the brain are intact and functioning properly.

Choice B reason: This is correct. Great toe bending upward, and smaller toes fanning outward is an abnormal response in adults. It indicates a positive Babinski reflex, which is a sign of damage to the cerebral cortex or the pyramidal tract. The cerebral cortex is the outer layer of the brain that controls higher functions such as thinking, reasoning, and movement. The pyramidal tract is a bundle of nerve fibers that connects the cerebral cortex to the spinal cord and controls voluntary movements.

Choice C reason: This is incorrect. Great toe bending downward is also a normal response in adults. It indicates that the spinal cord and the brain are intact and functioning properly.

Choice D reason: This is incorrect. The opposite foot assuming the same position as the foot being stroked is not related to the Babinski reflex. It is a phenomenon called mirror movement, which may occur in some people due to genetic or developmental factors. It does not indicate any abnormality in the cerebral cortex.

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Correct Answer is C

Explanation

Choice A reason: Evening is not the best time to visit the patient with myasthenia gravis to help with bathing and exercising. Myasthenia gravis is a condition that causes muscle weakness and fatigue, which worsens as the day progresses. Therefore, the patient may have more difficulty performing these activities in the evening.

Choice B reason: Mid-afternoon is not the best time to visit the patient with myasthenia gravis to help with bathing and exercising. Myasthenia gravis causes muscle weakness and fatigue, which may be aggravated by the heat and humidity of the afternoon. Therefore, the patient may have more difficulty performing these activities in the mid-afternoon.

Choice C reason: Morning is the best time to visit the patient with myasthenia gravis to help with bathing and exercising. Myasthenia gravis causes muscle weakness and fatigue, which are less severe in the morning after a night of rest. Therefore, the patient may have more strength and energy to perform these activities in the morning.

Choice D reason: Before bedtime is not the best time to visit the patient with myasthenia gravis to help with bathing and exercising. Myasthenia gravis causes muscle weakness and fatigue, which are most severe at the end of the day. Therefore, the patient may have more difficulty performing these activities before bedtime.

A. Apples, oranges and strawberries B. Tuna fish, white bread and green vegetables C. Lean beef, raisins and prunes D. White chicken meat, whole milk and rice

Correct Answer is C

Explanation

Choice A reason: This is incorrect. Apples, oranges and strawberries are good sources of vitamin C, which can help with iron absorption, but they are not high in iron content themselves. The patient should eat foods that are rich in both iron and vitamin C.

Choice B reason: This is incorrect. Tuna fish, white bread and green vegetables are not high in iron content either. Tuna fish is a source of protein, but it has less iron than other types of meat or fish. White bread is refined and has less iron than whole grain bread. Green vegetables have some iron, but not enough to meet the daily requirements.

Choice C reason: This is correct. Lean beef, raisins and prunes are high in iron content and can help the patient with iron deficiency anemia. Lean beef is a source of heme iron, which is more easily absorbed by the body than non-heme iron from plant sources. Raisins and prunes are dried fruits that have more iron than fresh fruits.

Choice D reason: This is incorrect. White chicken meat, whole milk and rice are not high in iron content either. White chicken meat has less iron than dark chicken meat or red meat. Whole milk is a source of calcium, which can interfere with iron absorption. Rice is a source of carbohydrates, but it has less iron than other grains or legumes.

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The nurse evaluates the Babinski reflex and strokes the sole of the patient's foot from the outer heel to the little toe. The patient was in an automobile accident and has a decreased level of consciousness. Which response indicates an abnormality in the cerebral cortex?

Nursing Test Bank

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