A 75-year-old client with a recent history of a cerebrovascular accident (CVA) presents with right hemiparesis. The nurse tests the deep tendon reflexes on the right side and elicits a brisk 4+ response. Which interpretation of this finding is accurate?

Absent or sluggish response consistent with a lower motor neuron lesion.

Flaccid paralysis.

Hyperactive response consistent with an upper motor neuron disorder.

A normal reflex

Answer and Explanation

The Correct Answer is C

A.   An absent or sluggish deep tendon reflex typically indicates a lower motor neuron lesion, which affects the peripheral nerves or spinal cord segments involved in reflex arc processing. Lower motor neuron lesions often result in reduced or absent reflexes, not brisk responses.
B.   Flaccid paralysis is characterized by a lack of muscle tone and reflexes, which is usually associated with lower motor neuron damage. A brisk 4+ reflex response does not indicate flaccid paralysis but rather heightened reflex activity.
C.   A brisk 4+ response indicates hyperactivity of the deep tendon reflexes, which is consistent with an upper motor neuron disorder. Upper motor neuron lesions, such as those resulting from a cerebrovascular accident (CVA), often lead to increased reflex responses due to disruption in the normal inhibitory signals from the brain.
D.   A normal reflex response is typically classified as 2+ on a scale of 0 to 4, where 2+ is considered average or expected. A 4+ response indicates hyperactivity, which is not normal but rather indicates increased reflexes, usually associated with upper motor neuron issues.

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Correct Answer is C

Explanation

A. A standing position leaning over the exam bed may not provide the best view or allow for thorough examination of the perianal area. This position is less commonly used and may not be ideal for a focused assessment of hemorrhoids.
B. Finding out if the client uses over-the-counter preparations for hemorrhoids provides useful information about the management and treatment approach being used. However, while this information is valuable, it does not directly involve the physical assessment of the hemorrhoids themselves.
C. The left lateral position (also known as the Sims' position) is commonly used for the examination of the perianal area. It provides optimal access for visual inspection of hemorrhoids, fissures, or other abnormalities in the anal region. This position allows the nurse to examine the area more thoroughly and comfortably, making it the most appropriate choice for a focused assessment of hemorrhoids.

D. Asking about the duration of discomfort provides valuable information about the history and progression of the condition. Understanding how long the client has been experiencing symptoms can help in assessing the chronicity and possible treatment history of the hemorrhoids.

A. Numeric pain intensity scale. B. Apical-radial pulse deficit. C. Anteroposterior (AP) chest diameter. D. Body temperature.

Correct Answer is A

Explanation

A. The numeric pain intensity scale is a direct and effective method to assess the level of pain a patient is experiencing. If a client is splinting their chest, it’s essential to evaluate their pain level to determine the severity and guide appropriate pain management strategies. This is likely the most relevant and immediate follow-up assessment in this scenario.
B. An apical-radial pulse deficit measures the difference between the apical pulse (heart rate auscultated at the apex of the heart) and the radial pulse (heart rate palpated at the wrist). This assessment is used to detect conditions such as atrial fibrillation or other arrhythmias and is not directly related to the client’s chest splinting. Therefore, it is not the most relevant follow-up assessment in this context.
C. The anteroposterior (AP) chest diameter assessment is used to evaluate conditions such as barrel chest, which can be associated with chronic respiratory conditions. While this measurement can be important for assessing chronic respiratory issues, it is not directly related to the immediate concern of chest splinting, which is more likely associated with acute pain or discomfort.
D. Measuring body temperature is important for assessing the presence of fever or infection, but it does not directly address the client’s immediate complaint of chest pain or discomfort. While an elevated temperature might be relevant if an infection is suspected, it is not the most direct or immediate follow- up assessment for the observed behavior of splinting the chest.

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A 75-year-old client with a recent history of a cerebrovascular accident (CVA) presents with right hemiparesis. The nurse tests the deep tendon reflexes on the right side and elicits a brisk 4+ response. Which interpretation of this finding is accurate?

Nursing Test Bank

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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