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. Increase in sexual desire. B. Cessation of menstruation. C. Excessive vaginal moisture. D. Drenching night sweats.

Correct Answer is D

Explanation

A. This is unlikely to be associated with perimenopause. Often, perimenopause is linked to hormonal fluctuations that can lead to decreased libido rather than an increase.
B. While cessation of menstruation may indicate menopause, it is not typically seen during the perimenopausal phase, which is the time leading up to menopause. Perimenopause is characterized by irregular periods, not complete cessation.
C. Perimenopausal symptoms typically involve a decrease in vaginal moisture due to reduced estrogen levels. Excessive vaginal moisture would not be indicative of perimenopause and might suggest an infection or other conditions.
D. This is a classic symptom of perimenopause. Hormonal fluctuations during this time can lead to hot flashes and night sweats, which are commonly experienced as part of the transition toward menopause.

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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?

Nursing Test Bank

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

The nurse is obtaining a health history for a client during an annual physical examination. When evaluating the client for menopausal symptoms, which finding indicates the client is perimenopausal?

Correct Answer is D

Explanation

Which assessment finding, obtained during chest auscultation, should the nurse consider a normal finding?

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