When assessing motor function, which of the following are correct? (Select all that apply.)
a. The presence of a Babinski reflex is an abnormal finding in an adult.
b. Lower extremity muscle tone is assessed by asking the patient to push or pull his or her foot against resistance.
c. When using noxious stimuli to elicit a motor response, each limb is tested separately.
d. Abnormal extension, or decerebrate posturing, indicates a less positive outcome than abnormal flexion.
e. Evaluation of deep tendon reflexes is an essential part of the nursing assessment.
A, C, D
The presence of a Babinski response in an adult is indicative of neurologic dysfunction, pushing or pulling against resistance tests muscle strength, and deep tendon reflexes are not routinely checked by the critical care nurse during assessment.
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A nursing instructor is working with a Native-American student nurse. When the student is late for the first clinical day, the instructor states, "I'm not surprised she's late; Native-American students are always late."
The instructor's statement is an example of a. prejudice. b. stereotyping. c. ethnocentrism. d. discrimination.
The categories of outcome indicators include:
a. process and reliability. b. clinical and functional. c. process and evaluation. d. measurement and evaluation.
A nurse records a pulse rate of 170 beats/minute on a patient's flow chart. For which of the following age groups would this be considered a normal reading?
A) Newborn B) Ten-year-old C) Adolescent D) Adult