A client's patellar reflex is normal for the right side but diminished on the left. Using the scale for grading reflexes, how should the nurse document this finding?

Right knee +1; Left knee 0

Right knee +3; Left knee +2

Right knee +2; Left knee +1

Right knee +4; Left knee +3

Answer and Explanation

The Correct Answer is C

A) Right knee +1; Left knee 0: The scale for grading reflexes typically ranges from 0 to 4. A score of 0 indicates no reflex, which does not align with the description of having a diminished but not absent reflex. A score of +1 suggests a reduced but present reflex, which would be appropriate for a diminished reflex on the left side.

B) Right knee +3; Left knee +2: A score of +3 indicates an exaggerated or brisk reflex, while +2 denotes a normal reflex. Since the right knee reflex is normal, it should be documented as +2. A diminished reflex on the left side is more accurately reflected by a score of +1, not +2.
C) Right knee +2; Left knee +1: This is the most accurate documentation. A score of +2 denotes a normal reflex, which applies to the right knee. A score of +1 reflects a diminished reflex, which is appropriate for the left knee where the reflex is present but reduced.
D) Right knee +4; Left knee +3: A score of +4 represents a very brisk or hyperactive reflex, which is not consistent with a normal finding. Similarly, a score of +3 would indicate an exaggerated reflex, which does not fit the description of the right knee being normal. The correct grading for a normal reflex is +2, and for a diminished reflex is +1.

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. Stiffening of the large arteries: Stiffening of the large arteries is a common age-related change and can contribute to increased systolic blood pressure. While this change can affect cardiovascular function, it does not directly increase the risk of falls as much as other factors.
B. Rise in the systolic blood pressure: An increase in systolic blood pressure often occurs with aging due to arterial stiffening. Elevated systolic blood pressure alone does not directly cause an increased risk of falls but is a part of the broader spectrum of cardiovascular changes.
C. Postural orthostatic hypotension: Postural orthostatic hypotension (OH) is characterized by a significant drop in blood pressure when a person stands up from a sitting or lying position, leading to dizziness or lightheadedness. This condition is common in older adults and significantly increases the risk of falls, as it can cause sudden dizziness and unsteadiness upon standing.
D. Decline of pacemaker cells in the sino-atrial node: The decline of pacemaker cells in the sinoatrial node can lead to bradycardia or irregular heart rhythms, which are related to cardiac function. While this can affect overall cardiovascular health, it does not directly contribute to the risk of falls as much as the sudden changes in blood pressure associated with postural orthostatic hypotension.

A. hypoxia B. anemia C. hypotension D. Pneumonia

Correct Answer is C

Explanation

A) Hypoxia: Although the client's oxygen saturation is slightly decreased at 95% on room air, it is not critically low. Hypoxia could be a concern, but it is secondary to other more immediate issues, such as hypotension, that might be causing the low oxygen saturation.
B) Anemia: The client’s hemoglobin and hematocrit levels are low, indicating anemia. While anemia is a significant concern, it does not pose an immediate threat compared to hypotension, which can lead to more severe complications if not addressed promptly.
C) Hypotension: The client’s blood pressure is notably low at 82/58 mm Hg. Hypotension can lead to inadequate perfusion of vital organs and may be a result of or contribute to other issues such as sepsis or significant blood loss. Immediate attention to correcting hypotension is crucial to prevent further complications.
D) Pneumonia: The client presents with symptoms suggestive of pneumonia, including a productive cough, fever, and elevated white blood cell count. While pneumonia is a critical condition that requires treatment, addressing hypotension is a more urgent priority as it directly impacts the client's circulatory stability and overall well-being.

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 client's patellar reflex is normal for the right side but diminished on the left. Using the scale for grading reflexes, how should the nurse document this finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When assessing an older adult client, the nurse notes which age-related changes of the cardiovascular system that increase the risk for falls?

Correct Answer is C

Explanation

Correct Answer is C

Explanation

When the nurse is assessing a client's mental status as part of the neurological examination, which question would be most appropriate to ask?

A 16-year-old female client presents with complaints of palpitations. While the nurse is auscultating heart sounds, asking the client to get into a seated position and leaning forward, would help the nurse assess the presence of which of the following?

How would the nurse assess CN VIII Acoustic, vestibulocochlear: Select all that Apply

A client's patellar reflex is normal for the right side but diminished on the left. Using the scale for grading reflexes, how should the nurse document this finding?

A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan?

During a respiratory physical assessment, the nurse directs the patient to say and repeat the letter E for the transmitted voice sounds assessment. The nurse by auscultation hears the letter A instead of E. This is known as:

A nursing student asked the respiratory floor nurse why the adventitious wheezing breath sounds are present in asthmatic patients. The nurse should respond:

A nurse is assessing a patient that presents with a chief complaint of decreased sensation in the feet and non-healing ulcers on the soles of his foot. The picture below shows the patient's foot. What is likely causing the patient's symptoms?