Nokea
The nurse will document which reflex is present when there is dorsiflexion of the great toe with fanning of other toes?
- A. Brudzinski
- B. Babinski (damage to the corticospinal tracts)
- C. Trousseaus
- D. Kernigs
Correct Answer: B
Rationale: The Babinski reflex, characterized by dorsiflexion of the great toe and fanning of the other toes, is abnormal in adults and indicates damage to the corticospinal tract. This reflex is normal in infants but disappears as the nervous system matures. Its presence in adults suggests neurological pathology.
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A patient in traction frequently voices discomfort. Which one of the following complaints by Mrs. Iris would indicate beginning decubitus formation?
- A. Numbness of her toes on her left foot
- B. Pain around the insertion of the Kirschner wire
- C. Stiffness and aching of the right ankle
- D. Burning pain in the sacral area
Correct Answer: D
Rationale: Burning pain in the sacral area can indicate pressure sores forming due to prolonged pressure.
What does an abnormal finding in the assessment of the patient's motor function suggest?
- A. Possible neurological impairment or muscle weakness.
- B. Normal muscle strength and coordination.
- C. Absence of neurological symptoms.
- D. Stable and symmetrical muscle function.
Correct Answer: A
Rationale: Abnormal motor function findings, such as weakness or asymmetry, suggest possible neurological impairment. Normal strength, coordination, and stable function are expected findings.
What should be included in the management during the first 48 hours after an acute soft tissue injury of the ankle (select one that doesn't apply)?
- A. Use of elastic wrap
- B. Initial immobilization and rest
- C. Elevation of ankle above the heart
- D. Alternating the use of heat and cold
Correct Answer: D
Rationale: The initial management includes rest, ice, compression, and elevation (RICE) to reduce swelling and pain.
What characteristics are common in spondyloarthritides associated with human leukocyte antigen (HLA)€“B27?
- A. Symmetric polyarticular arthritis
- B. Absence of extraarticular disease
- C. Presence of rheumatoid factor and autoantibodies
- D. High level of involvement of sacroiliac joints and the axial skeleton
Correct Answer: D
Rationale: Spondyloarthritides primarily affect the axial skeleton.
Which statement by a patient with osteoporosis indicates the need for additional teaching?
- A. I take my ibuprofen every morning as soon as I get up.
- B. My daughter removed all of the throw rugs in my home.
- C. My husband helps me every afternoon with range-of-motion exercises.
- D. I rest in my recliner chair every day for at least an hour.
Correct Answer: A
Rationale: Regular intake of ibuprofen without guidance might interfere with bone health and should be discussed with healthcare providers.