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 C

Explanation

A. A lifestyle with minimal physical activity may contribute to general health issues, but it is not as directly linked to erectile dysfunction as conditions like diabetes.
B. Working long hours can cause stress or fatigue, which may indirectly affect sexual function, but it is not a direct cause of erectile dysfunction.
C. Type 2 diabetes mellitus is a well-known risk factor for erectile dysfunction due to its impact on blood flow and nerve function, both of which are essential for normal erectile function.
D. A phosphodiesterase inhibitor is often used to treat erectile dysfunction, but its presence on the medication list is more likely a treatment rather than a cause.

A. Brudzinski reflexes B. Muscle tone C. Romberg's test D. Level of consciousness E. Pupil size F. Cranial nerves G. Glasgow coma scale

Correct Answer is ["B","C","D","E","F","G"]

Explanation

A. Brudzinski reflexes test is primarily used to assess for meningeal irritation, which is not directly related to stroke.
B. Muscle tone assessments help to identify abnormalities in motor function, which could indicate neurological damage. Given the patient’s history and the recent fall, muscle tone should be checked for any signs of weakness or spasticity.
C. This test evaluates the client’s balance and proprioception. It is a quick way to check for potential issues with the nervous system, such as ataxia or other motor impairments, which could be present in a client with a stroke.
D. Assessing the level of consciousness is critical in a neurological assessment to ensure that the client is oriented and alert, which is especially important after a fall or stroke-like symptoms.
E. Pupillary response is an essential part of a neurological exam. Checking the size and reactivity of the pupils helps to assess brainstem function and overall neurological health.
F. Cranial nerve function should be assessed to evaluate for signs of neurological deficits. In stroke patients, cranial nerve impairments can provide important diagnostic information.
G. The Glasgow Coma Scale (GCS) is a standard tool for assessing the level of consciousness and neurological status. It can provide valuable insights into the severity of a neurological condition, especially in post-fall or post-stroke patients.

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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

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Correct Answer is C

Explanation

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Correct Answer is ["B","C","D","E","F","G"]

Explanation

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