The nurse observes that a client who is intoxicated has an ataxic gait. Which finding does the nurse expect to be positive upon further assessment of the client?
Battle sign.
Chvostek's sign.
Romberg sign.
Babinski sign.
The Correct Answer is C
A. Battle sign refers to bruising behind the ears and is a sign of head trauma, not intoxication.
B. Chvostek's sign is related to hypocalcemia, not intoxication.
C. Romberg sign assesses for balance issues when standing with eyes closed and is commonly positive in clients with neurological impairment, including intoxication.
D. Babinski sign is related to neurological disorders and would not be directly associated with intoxication.
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Correct Answer is D
Explanation
A. An extension of the great toe and fanning of other toes is known as a positive Babinski sign, which is abnormal in adults. This response is typically seen in infants but indicates neurological damage or dysfunction in adults.
B. An exaggerated reflex would usually refer to hyperreflexia, but the Babinski sign specifically involves the abnormal extension of the toes, not just an exaggerated reflex. This response is more associated with neurological damage than simple exaggeration.
C. The Babinski sign can sometimes be associated with central nervous system issues, including meningeal irritation. However, meningeal irritation often involves other symptoms such as neck stiffness, fever, and photophobia, which are not mentioned here.
D. A positive Babinski sign is a classic indication of pyramidal tract disease, which affects the corticospinal tract. This type of neurological dysfunction can be seen in conditions like stroke, multiple sclerosis, or brain injury.
Correct Answer is C
Explanation
A. While vaginal discharge, genital warts, and abdominal tenderness may indicate other concerns, they are not as directly related to menstrual irregularity without further investigation.
B. Breast tenderness, tremors, and high blood pressure are less likely to be connected to missed periods in this context.
C. Body weight changes, hirsutism, and thyroid enlargement could indicate thyroid dysfunction, such as hypothyroidism or polycystic ovary syndrome (PCOS), both of which can cause irregular periods.
D. Urinary frequency, unsteady gait, and dental erosion are more indicative of a metabolic or neurological issue, which is less likely to explain missed periods.
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