The nurse is testing superficial reflexes on an adult patient. When stroking up the lateral side of the sole and across the ball of the foot, the nurse notices the plantar flexion of the toes. How should the nurse document this finding?

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Question 1 of 5

The nurse is testing superficial reflexes on an adult patient. When stroking up the lateral side of the sole and across the ball of the foot, the nurse notices the plantar flexion of the toes. How should the nurse document this finding?

Correct Answer: C

Rationale: The correct answer is C: Plantar reflex present. This is the correct documentation for observing plantar flexion of the toes during stroking of the sole. This response indicates a normal plantar reflex, also known as the Babinski reflex, in adults. A positive Babinski sign (choice A) would involve dorsiflexion of the big toe and fanning of the other toes, which is abnormal in adults. Choice B (Plantar reflex abnormal) is incorrect because the observed plantar flexion is actually a normal response. Choice D (Plantar reflex 2+ on a scale from '0 to 4+') is not appropriate for documenting superficial reflexes.

Question 2 of 5

A patient is unable to perform rapid alternating movements such as rapidly patting her knees. The nurse should document this inability as:

Correct Answer: C

Rationale: Step 1: Rapid alternating movements inability is characteristic of dysdiadochokinesia. Step 2: Dysdiadochokinesia is the inability to perform rapid alternating movements due to cerebellar dysfunction. Step 3: Ataxia is a general term for lack of coordination but does not specifically refer to rapid alternating movements. Step 4: Astereognosis is the inability to recognize objects by touch, not related to rapid alternating movements. Step 5: Loss of kinesthesia is the loss of ability to sense body position and movement but does not specifically involve rapid movements. Summary: Choice C is correct as it directly relates to the patient's inability to perform rapid alternating movements. Choices A, B, and D are incorrect as they do not specifically address the patient's symptom.

Question 3 of 5

The nurse is assessing the vital signs of a 78-year-old patient. His temperature is 36.5°C (97.7°F), pulse is 90 beats per minute, respiratory rate is 18 breaths per minute, and blood pressure is 138/80 mm Hg. The nurse notices that the patient is slightly confused and asks the nurse if she can help him with anything. The nurse should:

Correct Answer: D

Rationale: The correct answer is D. 1. Monitoring for changes in the patient's condition is crucial to identify any deterioration or improvement. 2. Assessing for dehydration or infection is important as these conditions can cause confusion in elderly patients. 3. Rechecking vital signs may not provide additional information if they are within normal limits. 4. Obtaining a complete neurologic examination is not necessary at this point as the patient's confusion may be due to a more common cause like dehydration or infection. 5. Administering a sedative to relieve confusion is not appropriate without identifying and addressing the underlying cause. In summary, option D is the best course of action as it focuses on monitoring the patient's condition, assessing for potential causes of confusion, and addressing any underlying issues.

Question 4 of 5

The nurse wants to assess for disturbances in circadian rhythms in a patient admitted for depression. Which question best implements this assessment?

Correct Answer: C

Rationale: Rationale: Choice C is correct because it directly addresses circadian rhythms by asking about the patient's best and worst times of day, which helps assess their sleep-wake cycle disturbances common in depression. Choices A and D focus on hallucinations and cognitive functioning, not circadian rhythms. Choice B is related to memory impairment, not circadian rhythm disturbances.

Question 5 of 5

A patient has symptoms of acute anxiety related to the death of a parent in an automobile accident 2 hours earlier. The nurse should prepare to teach the patient about a medication from which group?

Correct Answer: D

Rationale: The correct answer is D, Benzodiazepines. In acute anxiety, fast-acting anxiolytics like benzodiazepines are effective in providing immediate relief by enhancing the effects of GABA neurotransmitter, reducing anxiety symptoms quickly. Tricyclic antidepressants (A) are not ideal for acute anxiety due to slow onset of action. Atypical antipsychotics (B) are not first-line treatment for anxiety. Anticonvulsants (C) are not typically used for acute anxiety.

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