A 21-year-old patient with a head injury resulting from trauma, is unconscious with no other injury. During assessment which expected finding will the nurse find when testing the patient's deep tendon reflexes (DTRs)?
Reflexes cannot be elicited.
Some reflexes will be present, depending on the area of injury.
Reflexes will be normal.
All reflexes will be diminished but present.
The Correct Answer is B
A. Reflexes cannot be elicited: Even in unconscious patients, deep tendon reflexes (DTRs) may still be present unless there is specific spinal cord or peripheral nerve damage. Complete absence of reflexes is not expected solely from a head injury.
B. Some reflexes will be present, depending on the area of injury: While localized brain injury can affect voluntary motor control, DTRs are spinal reflexes and are generally preserved regardless of the site of brain trauma.
C. Reflexes will be normal: Deep tendon reflexes are intact in unconscious patients without spinal cord injury. The reflex arc operates independently of the patient’s level of consciousness, so normal DTRs are an expected finding.
D. All reflexes will be diminished but present: Reflex responses may vary; some may be normal, some diminished, and some exaggerated depending on the affected pathways. It is unlikely that all reflexes are uniformly diminished in head trauma without spinal involvement.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Bell's palsy: Bell’s palsy involves paralysis of the facial nerve (cranial nerve VII), leading to weakness or drooping on one side of the face. It does not typically impair sensory function such as distinguishing between sharp and dull sensations.
B. Damage to the trigeminal nerve: The trigeminal nerve (cranial nerve V) is responsible for facial sensation, including sharp and dull differentiation. Damage to this nerve would explain bilateral sensory deficits across the face.
C. Scleroderma with a pronounced proliferation of connective tissue in the face and cheeks: Scleroderma causes skin thickening and tightening but does not directly impair nerve sensation. While facial appearance and mobility may change, sensory function remains intact.
D. Frostbite with resultant paresthesia to the cheeks: Frostbite can cause temporary numbness, tingling, or pain, but it usually affects localized skin tissue and is not typically symmetrical across the entire face.
Correct Answer is B
Explanation
A. Statements from witness: Having a witness statement can strengthen the case, but it is not a requirement before a nurse makes a report. Mandatory reporting focuses on ensuring early protection for the child even if no one directly observed the abuse.
B. Suspicion of child abuse and neglect: Nurses are legally required to report whenever there is reasonable suspicion of abuse or neglect. The responsibility is to notify authorities, who will then investigate and determine whether abuse has occurred.
C. Statements from the victim: A child may not always disclose abuse due to fear, shame, or inability to communicate. Because of this, mandatory reporting laws do not require a direct statement from the victim before a report is made.
D. Proof of abuse and neglect: Proof is not necessary for reporting, as the nurse’s role is not to investigate or confirm abuse. Requiring proof would delay intervention, leaving the child at risk of further harm while awaiting evidence.
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