On assessment of the left plantar reflexes of an adult client, the nurse notes the response shown in the photograph below. What action does the nurse take after assessing this new finding?
a. Relay this abnormal finding to other members of the health care team.
b. Anticipate the need for cerebral angio-graphy to determine the cause.
c. Examine the family history for a potential genetic disorder.
d. Document the finding and continue the assessment.
A
This finding is a positive Babinski reflex. In clients older than 2 years of age, a positive Babinski reflex is considered abnormal and indicates central nervous system disease. The nurse should notify the health care provider and other members of the health care team because further inves-tigation is warranted.
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