The nurse is assessing the neurologic status of a patient. She uses the handle end of a reflex hammer to stroke the lateral aspect of the sole of the foot. She notes that the great toe dorsiflexes and the other toes spread out like a fan
What does this indicate?
a. A positive Romberg's test
b. A negative Babinski's reflex
c. A hyperactive patellar tendon reflex
d. A normal reflex in a child younger than age 2
D
After the soles of the feet are stroked, if Babinski's reflex is present, the great toe will dorsiflex, accompanied by fanning of the other toes. This indicates CNS dysfunction. Dorsiflexion of the great toe and fanning of the others are normal findings in a child younger than age 2 . Romberg's test: Have the patient stand with feet together, arms at sides, once with eyes open and once with eyes closed (for 20 to 30 seconds each time). Protect the patient's safety by standing at their side; observe for swaying. Plantar response (Babinski's reflex): Using the handle end of the reflex hammer, stroke the lateral aspect of the sole, from the heel to the ball of the foot. The toes should flex inward and downward. Knee reflex: Palpate the patellar tendon just below the patella . Tap the pointed end of the reflex hammer briskly on the tendon. Knee reflex is the most common DTR assessment performed. The normal response is knee extension.
You might also like to view...
A hospital patient's most recent blood work reveals a Ca2+ level of 14.2 mg/dL (normal 8.5 to 10.5 mg/dL) and a phosphorus level of 1.4 mg/dL (normal 3.0 to 4.5 mg/dL)
What hormone has the potential to cause this alteration in the patient's electrolyte levels? A) Calcitonin B) Corticotropin-releasing hormone (CRH) C) Thyroid hormone D) Parathyroid hormone
When working with a client who is attempting to lose weight, which of the following suggestions by the nurse might assist the client in being compliant with the prescribed diet?
1. Eat alone to reduce outside distractions. 2. Drink water or a diet beverage after eating to promote feelings of fullness. 3. Allow at least 45 minutes to 1 hour to promote full enjoyment of a meal. 4. Set aside small nonfood rewards when you meet a goal.
A patient is learning to improve her personal empowerment skills after going through a tough divorce. Which actions can she take to accomplish this? (Select all that apply.)
a. Practice positive self-talk. b. Manage the work of success. c. Develop an external locus of control. d. Eliminate self-defeating behaviors. e. Manage good health.
Unit safety is the responsibility of the housekeeping and maintenance departments.
Answer the following statement true (T) or false (F)