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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. The client’s current symptoms—pain, significant leg edema, and swelling—are more pressing and suggest a need to evaluate the physical cause of these symptoms rather than focusing immediately on mental status.
B. Obtaining a blood alcohol level might be relevant if there is a suspicion that recent alcohol use is contributing to the client’s condition or affecting his overall health. However, the primary concern in this case is the significant edema and pain in the left leg.
C. This is the most pertinent action to take first. The client’s symptoms of severe edema and pain in one leg, along with a history of CVA and alcohol abuse, raise concerns about possible causes such as deep vein thrombosis (DVT), infection, or trauma. Inspecting the legs for signs of infection or trauma (bruising, cuts) is crucial to determine the underlying cause of the symptoms and guide appropriate treatment.

D. While excessive salt intake can contribute to fluid retention and edema, the degree of swelling described (4+ pitting edema) and the localized nature of the problem in the left leg make it less likely that dietary salt alone is the cause.

A. Nodes feel ropey and rubbery. B. Axillary nodes feel soft and fatty. C. Inguinal nodes are enlarged and warm to the touch. D. Nodes are non-palpable.

Correct Answer is D

Explanation

A. Lymph nodes that feel ropey and rubbery might indicate chronic inflammation or fibrosis. This texture is not typically considered normal. In elderly clients, lymph nodes may become less palpable due to age- related changes, but they should not feel ropey or rubbery. If lymph nodes feel this way, it may warrant further investigation to rule out pathological conditions.
B. In elderly clients, axillary lymph nodes may feel softer and less defined due to fatty tissue changes associated with aging. However, "soft and fatty" should be interpreted cautiously. While some degree of change is normal, nodes should not be excessively soft, nor should they have an abnormal appearance. The key is that they should not be hard, fixed, or tender, which would be indicative of pathology.
C. Enlarged and warm inguinal lymph nodes suggest infection or inflammation rather than a normal finding. In the elderly, while lymph nodes can sometimes be palpable, they should not be enlarged or warm, as this could indicate an underlying condition or infection that requires further evaluation.
D. It is normal for lymph nodes to be non-palpable in many individuals, including older adults. Age- related changes can cause lymph nodes to be less prominent or difficult to palpate. If lymph nodes are non-palpable, it usually means they are not enlarged or abnormal, which is a normal finding, especially if the client is not experiencing any symptoms of infection or other related issues.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

The nurse has just completed palpation maneuvers for lymph nodes on an older adult female client. Which findings are considered normal for this elderly client?

Correct Answer is D

Explanation

Which finding should raise the greatest concern for a nurse who is performing an ear nose and throat (ENT) examination?

The nurse is assessing older clients in a community health clinic. Which assessment finding is an indicator for immediate medical follow-up?

While performing a mental status examination, which question should the nurse ask when attempting to evaluate a client's judgment?

When inspecting a client's skin, the nurse observes an area of erythema on the arm. Which follow- up assessment should the nurse complete?

When assessing a client's level of consciousness, the nurse determines that the client is alert and ambulatory, but confused. Which follow- up assessment should the nurse complete next?

The nurse assesses a client with a sleep pattern disturbance. In developing a plan of care, what assessment data should the nurse obtain first?