The nurse recognizes which of the following observations as a positive Babinski sign?
1. Dorsiflexion of the great toe, with fanning of the other toes
2. Curling of all the toes in response to stroking stimulation
3. Feeling a buzzing sensation in the foot when touched with a tuning fork
4. Inability to identify two simultaneous points of pain on the foot
Dorsiflexion of the great toe, with fanning of the other toes
Rationale: Dorsiflexion of the great toe, with fanning of the other toes, shows pathologic reflexes (positive Bakinski sign). Vibratory sense is tested using a tuning fork on one of a variety of bony prominences. Diminished buzzing sensation is pathological. Two-point discrimination is tested by touching the client with one or both sharp objects at the same time; the inability to identify if there were multiple pain sites reflects pathology.
You might also like to view...
A patient who takes lithium phones the nurse at the clinic to say, "I've had diarrhea for 4 days. I feel weak and unsteady when I walk. My usual hand tremor has gotten worse. What should I do?" Which instruction by the nurse is appropriate?
a. "Have someone bring you to the clinic immediately.". b. "Restrict food and fluids for 24 hours and stay in bed.". c. "Drink a large glass of water with 1 teaspoon of salt added.". d. "Take antidiarrheal medication hourly until the diarrhea subsides.".
The nurse manager is preparing a teaching session on suicide for a group of novice nurses. What will the nurse manager include in the teaching? Select all that apply
1. Women commit suicide more than men. 2. Men commit suicide more than women. 3. Women have a higher rate of attempted suicide. 4. Older adults commit suicide more than younger adults. 5. Younger adults commit suicide more than older adults.
A patient with bipolar disorder has stabilized and is being discharged from the hospital. The patient will live independently at home but lacks social skills and transportation. Which referral would be most appropriate?
a. A group home b. A self-help group c. A day treatment program d. Assertive community treatment (ACT)
It is important to verify that a drug order contains all information needed to carry it out safely and
accurately. Indicate whether the statement is true or false