The Nurse Is Assessing the Neurologic Status of a Patient

Multiple Choice

The nurse is assessing the neurologic status of a patient who has a late-stage brain tumor. With the reflex hammer, the nurse draws a light stroke up the lateral side of the sole of the foot and inward, across the ball of the foot. In response, the patient's toes fan out, and the big toe shows dorsiflexion. How should the nurse interpret these findings?

A) Clonus, which is a hyperactive response
B) Achilles reflex, which is an expected response
C) Negative Babinski sign, which is normal for adults
D) Positive Babinski sign, which is abnormal for adults