The nurse observes that a client who is intoxicated has an ataxic gait. Which finding does the nurse expect to be positive upon further assessment of the client?
Explanation & Rationale
A. Babinski sign. The Babinski reflex is an abnormal neurological response in adults where the toes fan outward when the sole of the foot is stroked. It is typically associated with upper motor neuron lesions rather than alcohol intoxication. B. Chvostek's sign. Chvostek's sign is a facial muscle spasm triggered by tapping the facial nerve and is associated with hypocalcemia. It is unrelated to ataxic gait or alcohol intoxication. C. Romberg sign. The Romberg test assesses balance by having the client stand with feet together and eyes closed. A positive Romberg sign (loss of balance) suggests impaired proprioception or cerebellar dysfunction, both of which can occur with alcohol intoxication. D. Battle sign. Battle sign refers to bruising behind the ear, which is indicative of a basilar skull fracture. It is not related to alcohol intoxication or ataxic gait.