When assessing the left foot planter reflex of an adult client, the nurse observes an extension of the great toe and fanning of other toes. Which interpretation of this finding is accurate?

Normal reflex response for age.

Exaggerated reflex response.

Beginning meningeal irritation.

Pyramidal tract disease.

Answer and Explanation

The Correct Answer is D

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.

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Correct Answer is A

Explanation

A. A Tinetti balance score of 12 and a gait score of 8 are indicative of an increased risk for falls. A total score below 19 suggests significant fall risk and a need for interventions to prevent injury.
B. While the results may reflect some age-related changes, they are lower than expected for a healthy older adult without significant mobility issues.
C. The results suggest an increased risk for falls but do not automatically indicate a need for a walker. Further assessment of functional capacity is needed.
D. The results do not specifically indicate Parkinson's disease, although balance and gait issues may be present in such conditions. Parkinson’s diagnosis would require additional motor and neurological assessments.

A. Left fifth intercostal space, midclavicular line. B. Third left intercostal space. C. Left fourth intercostal space next to left sternal border. D. Second right intercostal space.

Correct Answer is C

Explanation

A. The fifth intercostal space, midclavicular line, is the location for auscultating the mitral valve.
B. The third left intercostal space is typically used for the pulmonic valve.
C. The tricuspid valve is best auscultated at the left fourth intercostal space near the left sternal border.
D. The second right intercostal space is used to listen to the aortic valve.

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When assessing the left foot planter reflex of an adult client, the nurse observes an extension of the great toe and fanning of other toes. Which interpretation of this finding is accurate?

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Naxlex Comprehensive Predictor Exams

A nurse performs a Tinetti assessment on an older adult client and calculates a balance score of 12 and a gait score of 8. Which do these results indicate?

Correct Answer is A

Explanation

When assessing heart sounds of a client with rheumatic valvular heart disease, where should the nurse place the stethoscope to auscultate the tricuspid valve?

Correct Answer is C

Explanation

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