The nurse is assessing the neurological status of a patient.She uses the handle end of a reflex hammer to stroke the lateral aspect of the sole of the foot.She notes that the great toe dorsiflexes and the other toes spread out like a fan.What does this indicate?
A)A positive Romberg's test
B)A negative Babinski's reflex
C)A hyperactive patellar tendon reflex
D)A normal reflex in a child younger than age 2

Question

Quizplus · Accepted Answer

After the soles of the feet are stroked,if Babinski's reflex is present,the great toe will dorsiflex,accompanied by fanning of the other toes.This indicates CNS dysfunction.Dorsiflexion of the great toe and fanning of the others are normal findings in a child younger than age 2.Romberg's test: Have the patient stand with feet together,arms at sides,once with eyes open,and once with eyes closed (for 20 to 30 seconds each time).Protect the patient's safety by standing at their side;observe for swaying.Plantar response (Babinski's reflex): Using the handle end of the reflex hammer,stroke the lateral aspect of the sole,from the heel to the ball of the foot.The toes should flex inward and downward.Knee reflex: Palpate the patellar tendon just below the patella.Tap the pointed end of the reflex hammer briskly on the tendon.Knee reflex is the most common DTR assessment performed.The normal response is knee extension.

The Nurse Is Assessing the Neurological Status of a Patient