The nurse reviews charting from the last shift on a client. The chart states that the adult client's Babinski reflex is positive. What does the nurse understand from this documentation? (Select all that apply.)

Question

Quizplus · Accepted Answer

The Babinski reflex is a normal finding in infants up to 18 months when an examiner strokes the heel upward to just below the little toe, then across the ball of the foot toward the great toe with the rounded end of a reflex hammer handle or other tool. The normal response is dorsiflexion, or upgoing, of the great toe and fanning of the other toes. However, in adults, this is considered abnormal and is known as a positive Babinski reflex. This could indicate upper motor neuron defects or other neurologic conditions. Balance is tested with the Romberg test. Neck movement and strength is demonstrated by testing cranial nerve XI (accessory).

The Nurse Reviews Charting from the Last Shift on a Client