The nurse notes fanning of the toes when the sole of the foot is stimulated during assessment of the plantar reflex. The nurse would correctly chart which of the following?
1. Hyperreflexia
2. Babinski response
3. Brudzinski sign
4. Nuchal rigidity
2
Rationale 1: Hyperreflexia refers to a reflex that is abnormally strong.
Rationale 2: The Babinski response is fanning of the toes with the great toe pointing downward when the sole of the foot is stimulated. This response is considered abnormal in adults.
Rationale 3: Brudzinski sign refers to flexion of the legs and thighs when the neck is flexed and is an assessment used to confirm meningitis.
Rationale 4: Nuchal rigidity refers to stiffness of the neck and is most often seen in meningitis.
You might also like to view...
The nurse's obligations in ethical decisions include which of the following? Select all that apply
a. Be a patient advocate. b. Involve institutional ethics committees. c. Improve one's own ethical decision making. d. Respect patient confidentiality.
A client with chronic pain from herniated intervertebral disks is experiencing constipation. What intervention would be appropriate for this client?
A) Restrict foods high in fiber. B) Avoid the use of stool softeners. C) Encourage fluid intake of 2,500-3,000 ml each day. D) Medicate for pain around the clock.
A longitudinal study is tracking the effects of a program aimed at improving the health-related decision-making skills of teenagers over the course of their high school years
The researchers have had to account for maturation effects in the methodology of the study. Maturation would have which of the following effects on the study participants? A) A decrease in the effectiveness of the intervention with passing time B) An accumulation of the effects of the intervention over time that exaggerates its effectiveness C) Developmental changes in the participants that are not related to the intervention D) An increase in the sophistication and effectiveness of the intervention with repeated applications
The nurse is teaching the client to use a metered-dose inhaler. Which information should the nurse provide to the client?
1. Take a deep breath, hold it, and then gently squeeze the inhaler to dispense the medication. 2. Take several slow deep breaths in through the nose and out through the mouth, then squeeze the inhaler while taking a deep breath. 3. Exhale comfortably, squeeze the canister to discharge the medication, and inhale slowly and deeply through the mouth, then hold the breath for 10 seconds, or as long as possible. 4. Exhale deeply, squeeze the canister to discharge the medication, and inhale slowly and deeply through the mouth, then hold the breath for 10 seconds, and exhale through the nose.