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 that the toes curl down and away from the shin.How should the nurse document this finding?

Question

Quizplus · Accepted Answer

With the handle of the reflex hammer, the nurse can assess for the plantar reflex by drawing a light stroke up the lateral side of the sole of the foot and across the ball of the foot, similar to an upside-down "J." The normal response is plantar flexion of the toes (toes curl down) and sometimes of the entire foot.A positive Babinski sign is abnormal and occurs with the response of dorsiflexion of the big toe and fanning of all toes.The plantar reflex is not graded on a 0-to-4+ scale.

The Nurse Is Testing Superficial Reflexes on an Adult Patient