The Nurse Is Assessing the Neurological Status of a Patient

question 36

Multiple Choice

The nurse is assessing the neurological status of a patient who has a late-stage brain tumour.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:

• A)Negative Babinski sign, which is normal for adults
• B)Positive Babinski sign, which is abnormal for adults
• C)Clonus, which is a hyperactive response
• D)Achilles reflex, which is an expected response

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Definitions:

Delusion

A false belief firmly held despite clear or contradictory evidence, often encountered in psychiatric disorders.

Cheat

The act of behaving dishonestly or unfairly in order to gain an advantage, especially in a game, exam, or competition.

Lie

A false statement made with deliberate intent to deceive; an intentional untruth.

Acrophobia

An intense fear of heights, often leading to anxiety or panic when one is not grounded or in a high place.