Final answer:
A positive Babinski sign in an adult, especially a client with cirrhosis, indicates possible neurological damage or upper motor neuron disease. Hence, the nurse should perform a thorough neurological assessment to investigate further.
Step-by-step explanation:
The Babinski reflex is an important neurologic exam that involves stroking the plantar surface of the foot to observe toe movements. In adults, a positive Babinski sign indicates an abnormal finding, usually linked to a central nervous system issue, such as from conditions like cirrhosis which can affect the brain function due to toxins. This reflex is normally suppressed by corticospinal tract input, and its presence suggests a disruption in this pathway. A positive Babinski reflex can indicate upper motor neuron disease or serious neurological damage.
Upon observing a positive Babinski sign in a client with cirrhosis, the appropriate nurse response is to conduct a thorough neurologic examination. This may be inclusive of testing other reflexes, muscle strength, tone, and performing tests that assess cerebellar function. The presence of Babinski sign signifies potential upper motor neuron issues, which could be due to hepatic encephalopathy in patients with liver disease.
The nurse's evaluation can involve inquiries on recent alcohol use, as this could contribute to neurological changes, but this should follow after an immediate neurologic assessment. Keeping the client's feet elevated can alleviate edema but does not directly address the Babinski sign. Completing a thorough neurologic assessment would provide a broader understanding of the client's neurologic function and help in tailoring care appropriately.