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 A

Explanation

A. A limping gait can be a sign of pain or discomfort while walking. By asking about pain while bearing weight, the nurse can get a better understanding of the underlying cause of the limp.
B. A limping gait is not typically associated with changes in level of consciousness. This assessment is not relevant in this situation.

C. While a spinal deformity can cause a limping gait, it is not the most likely cause in this case. The nurse should first assess for pain while bearing weight to get a better understanding of the underlying issue.
D. Orthostatic blood pressure is a measure of blood pressure changes when a person stands up. It is not typically associated with a limping gait and is not relevant in this situation.

A. Notify the healthcare provider. B. Observe for eye opening to a painful stimulus. C. Check the pupillary response to light. D. Ask the client to open his eyes.

Correct Answer is B

Explanation

A. While notifying the healthcare provider is important if there are significant changes in the client's level of consciousness, it should not be the immediate next step. Before alerting the provider, the nurse needs to perform additional assessments to determine the extent of the client's unresponsiveness and gather more information about their neurological status.
B. Observing for eye opening in response to a painful stimulus is a critical step in assessing the depth of unconsciousness. This response helps determine the client's level of consciousness and can provide information about the severity of their condition.
C. Checking the pupillary response to light is important in evaluating neurological function and can provide information about brainstem activity and potential neurological deficits. However, it is secondary to checking for responses to stimuli like painful stimuli if the client is not opening their eyes spontaneously. Pupillary response should be assessed as part of a comprehensive neurological exam.
D. Asking the client to open his eyes might not be effective if the client is unresponsive or has impaired consciousness. If the client is not responding spontaneously, it is likely that verbal commands will also be ineffective. This step is less useful when assessing levels of consciousness compared to more objective assessments like responses to painful stimuli.

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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 B

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