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Question
A mother brings in her newborn infant for an assessment and tells the nurse that she has noticed that whenever her newborn's head is turned to the right side, she straightens out the arm and leg on the same side and flexes the opposite arm and leg. After observing this on examination, the nurse tells her that this reflex is:a. Abnormal and is called the atonic neck reflex.
b. Normal and should disappear by the first year of life.
c. Normal and is called the tonic neck reflex, which should disappear between 3 and 4 months of age.
d. Abnormal. The baby should be flexing the arm and leg on the right side of his body when the head is turned to the right.
Answer
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Related questions
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The nurse is preparing to perform a modified Allen test. Which is an appropriate reason for this test?
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c. To evaluate the adequacy of collateral circulation before cannulating the radial artery
d. To evaluate the venous refill rate that occurs after the ulnar and radial arteries are temporarily occluded
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When performing a peripheral vascular assessment on a patient, the nurse is unable to palpate the ulnar pulses. The patient's skin is warm and capillary refill time is normal. Next, the nurse should:
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a. Document the finding.
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Which statement is true regarding the arterial system?
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During a cardiovascular assessment, the nurse knows that a thrill is:
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In assessing for an S4 heart sound with a stethoscope, the nurse would listen with the:
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b. Bell of the stethoscope at the apex with the patient in the left lateral position.
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Q:
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A patient has been admitted to the emergency department with a possible medical diagnosis of pulmonary embolism. The nurse expects to see which assessment findings related to this condition?
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Q:
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Q:
Which of these statements is most appropriate when the nurse is obtaining a genitourinary history from an older man?
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d. "Has anyone ever touched your genitals when you did not want them to?"
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In a person with an upper motor neuron lesion such as a cerebrovascular accident, which of these physical assessment findings should the nurse expect?
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d. Atrophy and wasting of the muscles
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A 78-year-old man has a history of a cerebrovascular accident. The nurse notes that when he walks, his left arm is immobile against the body with flexion of the shoulder, elbow, wrist, and fingers and adduction of the shoulder. His left leg is stiff and extended and circumducts with each step. What type of gait disturbance is this individual experiencing?
a. Scissors gait
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c. Parkinsonian gait
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Q:
During an assessment of a 32-year-old patient with a recent head injury, the nurse notices that the patient responds to pain by extending, adducting, and internally rotating his arms. His palms pronate, and his lower extremities extend with plantar flexion. Which statement concerning these findings is most accurate? This patient's response:
a. Indicates a lesion of the cerebral cortex.
b. Indicates a completely nonfunctional brainstem.
c. Is normal and will go away in 24 to 48 hours.
d. Is a very ominous sign and may indicate brainstem injury.
Q:
While assessing a 7-month-old infant, the nurse makes a loud noise and notices the following response: abduction and flexion of the arms and legs; fanning of the fingers, and curling of the index finger and thumb in a C position, followed by the infant bringing in the arms and legs to the body. What does the nurse know about this response?
a. This response could indicate brachial nerve palsy.
b. This reaction is an expected startle response at this age.
c. This reflex should have disappeared between 1 and 4 months of age.
d. This response is normal as long as the movements are bilaterally symmetric.