Author Question: When assessing a patient, the nurse elicits the Babinski reflex on the left foot. The nurse knows ... (Read 78 times)

darbym82 · **on:** Jul 19, 2018

When assessing a patient, the nurse elicits the Babinski reflex on the left foot. The nurse knows this response can indicate the existence of

a. an upper motor neuron lesion on the right side.
b. an upper motor neuron lesion on the left side.
c. a lower motor neuron lesion on the right side.
d. a lower motor neuron lesion on the left side.

Question 2

A patient is withdrawn, suspicious, and maintains physical distance from staff and other patients. Which intervention demonstrates appropriate use of touch with this patient?

a. Refraining from touch
b. Patting the patient's arm when fear is expressed
c. Reaching out to shake the patient's hand as an initial greeting
d. Placing an arm around the patient's shoulders while walking down the hall

cegalasso · **Reply #1 on:** Jul 19, 2018

Answer to Question 1

A
The Babinski sign is the result of an upper motor neuron lesion on the opposite (contralateral) side of the body. Lower motor neuron lesions normally result in flaccid paralysis.

Answer to Question 2

A
Withdrawn, suspicious patients often consider touch a violation of personal space or might misinterpret touch as being sexual or aggressive. Refraining from touching a suspicious patient is wise until there is evidence that the patient can tolerate touch. The more intimate or extensive the touching, the more threatening it might be to the patient.