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 A

Explanation

Choice A reason: Maintaining pressure to the puncture site and observing for drainage is the priority nursing intervention for a patient who had a lumbar puncture. It helps to prevent bleeding, hematoma, and cerebrospinal fluid leakage, which can cause complications such as infection, headache, or nerve damage.

Choice B reason: Completing a pain assessment and administering an ordered analgesic, as needed, is an important nursing intervention for a patient who had a lumbar puncture, but it is not the priority. Lumbar puncture can cause mild to moderate pain and discomfort at the puncture site, which can be relieved by analgesics, ice packs, or massage.

Choice C reason: Informing the patient they may feel pressure and sharp pain in their lower back for several hours is an important nursing intervention for a patient who had a lumbar puncture, but it is not the priority. Lumbar puncture can cause transient sensations of pressure and pain in the lower back, which can be reduced by lying flat, avoiding sudden movements, and drinking fluids.

Choice D reason: Assessing pulses distal to the lumbar puncture site every two hours is not an appropriate nursing intervention for a patient who had a lumbar puncture. Lumbar puncture does not affect the blood circulation to the lower extremities, unless there is a complication such as hematoma or nerve compression. Therefore, the nurse should monitor the neurological status, vital signs, and signs of infection or bleeding.

A. Observe the time of onset and end of seizure activity. B. Remove objects within reach of the client's arms and legs. C. Loosen any restrictive clothing around the neck. D. Place a padded tongue blade in the client's mouth

Correct Answer is B

Explanation

Choice A reason: Observing the time of onset and end of seizure activity is important, but it is not the priority action. The nurse should first ensure the safety of the client and prevent injury.

Choice B reason: Removing objects within reach of the client's arms and legs is the correct action, as it prevents the client from hitting or injuring themselves during the seizure. The nurse should also lower the bed and raise the side rails.

Choice C reason: Loosening any restrictive clothing around the neck is a good practice, but it is not as urgent as removing objects. The nurse can do this after ensuring the client's safety.

Choice D reason: Placing a padded tongue blade in the client's mouth is a wrong and dangerous action, as it can cause choking, aspiration, or damage to the teeth and oral mucosa. The nurse should never force anything into the client's mouth during a seizure.

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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

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient undergoing a lumbar puncture by the provider. Select the priority nursing intervention the nurse would complete after the procedure.

Correct Answer is A

Explanation

A nurse is caring for a client who begins to exhibit seizure activity while in bed. Which of the following actions should the nurse implement to care for the client?

Correct Answer is B

Explanation

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