A nurse assesses the left plantar reflexes of an adult client and ...

[jlmhmf]

A nurse assesses the left plantar reflexes of an adult client and notes the response shown in the photograph below: Which action should the nurse take next?
 
  a. Contact the provider with this abnormal finding.
  b. Assess bilateral legs for temperature and edema. c.
  Ask the client about pain in the lower leg and calf.
  d. Document the finding and continue the assessment.

Question 2

A nurse assesses a client and notes the client's position as indicated in the illustration below:
 
  How should the nurse document this finding?
  a.
  Decorticate posturing
  b.
  Decerebrate posturing
  c.
  Atypical hyperreflexia
  d.
  Spinal cord degeneration

[briezy]

Answer to Question 1

ANS: A
This finding indicates Babinski's sign. In clients older than 2 years of age, Babinski's sign is considered abnormal and indicates central nervous system disease. The nurse should notify the health care provider and other members of the health care team because further investigation is warranted. This finding does not relate to perfusion of the leg or to pain. This is an abnormal assessment finding and should be addressed immediately.

Answer to Question 2

ANS: A
The client is demonstrating decorticate posturing, which is seen with interruption in the corticospinal pathway. This finding is abnormal and is a sign that the client's condition has deteriorated. The physician, the charge nurse, and other health care team members should be notified immediately of this change in status. Decerebrate posturing consists of external rotation and extension of the extremities. Hyperreflexes present as increased reflex responses. Spinal cord degeneration presents frequently with pain and discomfort.

[jlmhmf]

TYSM

[phuda]

Gracias!