The nurse is assessing the neurologic status of a patient who has a late-stage brain tumor. With the reflex hammer, the nurse draws a light stroke up the lateral side of the sole of the foot and inward, across the ball of the foot. In response, the patient's toes fan out, and the big toe shows dorsiflexion. The nurse interprets this result as:

Correct Answer: B

Rationale: The correct answer is B: Positive Babinski sign, which is abnormal for adults. When the patient's toes fan out and the big toe dorsiflexes in response to the stroke with the reflex hammer on the sole of the foot, it indicates a positive Babinski sign. This abnormal response suggests upper motor neuron dysfunction, possibly due to the brain tumor affecting the corticospinal tract. In adults, a positive Babinski sign is indicative of pathology and not a normal finding. Summary: A: Incorrect - Negative Babinski sign is normal for adults, not applicable in this case. C: Incorrect - Clonus is characterized by rhythmic muscle contractions and is not demonstrated in the scenario described. D: Incorrect - Achilles reflex involves tapping the Achilles tendon to assess the integrity of the S1 nerve root, not relevant to the response observed in this scenario.

Correct Answer: B

Rationale: The correct answer is B: Dopamine-blocking effects. Restlessness and an uncontrollable need to be in motion are symptoms of extrapyramidal side effects, commonly caused by dopamine-blocking medications used to treat mental illness. Dopamine blockade can lead to an imbalance in the neurotransmitter system, resulting in movement disorders like akathisia. Anticholinergic effects (choice A) typically cause dry mouth and constipation, not restlessness. Endocrine-stimulating effects (choice C) would not manifest as restlessness. The ability to stimulate spinal nerves (choice D) is not directly related to the symptoms described.

Correct Answer: A

Rationale: The correct answer is A because clozapine can cause agranulocytosis, a serious condition where the body's white blood cell count drops significantly, leading to infections like sore throat and fever. Reporting these symptoms promptly is crucial for timely medical intervention. Choices B, C, and D are incorrect because they are not directly related to potential side effects or complications of clozapine therapy.

Correct Answer: D

Rationale: The correct answer is D: dopamine. Dopamine is implicated in the pathophysiology of schizophrenia, with increased dopamine activity thought to contribute to the positive symptoms of the disorder. This is supported by the effectiveness of antipsychotic medications that block dopamine receptors. GABA (A) is an inhibitory neurotransmitter, and its dysfunction is associated with anxiety disorders, not schizophrenia. Substance P (B) is primarily involved in pain perception and neurokinin receptors, not typically implicated in schizophrenia. Histamine (C) plays a role in the sleep-wake cycle and allergic responses, but is not a primary neurotransmitter involved in schizophrenia.

Correct Answer: B

Rationale: The correct answer is B: "You are experiencing a placebo effect. When we believe something will help, it usually does.” Rationale: 1. The nurse acknowledges the patient’s positive experience with the herb, validating the patient's perspective. 2. By mentioning the placebo effect, the nurse educates the patient about the potential psychological benefits of belief in a treatment. 3. The nurse's comment is non-judgmental and encourages open communication with the patient. 4. This response promotes patient empowerment in managing their health. Summary: A: Merely noting in the medical record does not address the patient’s experience or provide valuable information. C: This response is accusatory and may discourage the patient from sharing important information in the future. D: This statement is incorrect and may cause unnecessary fear or confusion for the patient.