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.

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Correct Answer is C

Explanation

A) 2: A muscle strength grade of 2 indicates that the muscle can move when gravity is eliminated, such as when the limb is supported. However, it does not have enough strength to move against gravity. This grade is not appropriate for the client described, as they can move both lower legs against gravity.
B) 3: A muscle strength grade of 3 means that the muscle can move the joint against gravity but without any additional resistance. This is less than the client’s described ability, as they can move their legs against some resistance.
C) 4: A muscle strength grade of 4 indicates that the muscle can move against gravity and moderate resistance. This matches the client’s ability to actively move both lower legs against gravity and some resistance, making it the correct documentation of their muscle strength.
D) 5: A muscle strength grade of 5 indicates normal muscle strength, where the muscle can move against gravity and full resistance without any signs of fatigue. Since the client is described as moving against some resistance but not full resistance, a grade of 5 would overestimate their current muscle strength.

A. Secondary B. Quaternary C. Tertiary D. Primary

Correct Answer is C

Explanation

A) Secondary: Secondary prevention involves early detection and intervention to manage or treat a disease in its early stages, such as screening for diabetes or monitoring blood glucose levels. Administering insulin does not fall under this category, as it is not about early detection but rather ongoing management.
B) Quaternary: Quaternary prevention focuses on minimizing the harm of medical interventions, avoiding overmedicalization, and improving the quality of life. This type of prevention is more about avoiding unnecessary treatments and ensuring the patient receives appropriate care. Administering insulin is not related to this concept.
C) Tertiary: Tertiary prevention aims to manage and mitigate the effects of an established disease to improve the quality of life and reduce complications. Administering insulin to a client with type 1 diabetes mellitus is an example of tertiary prevention because it is part of managing and treating the chronic condition to prevent complications and maintain health.
D) Primary: Primary prevention focuses on preventing the onset of disease through measures such as vaccination, lifestyle changes, or avoiding risk factors. Administering insulin does not prevent the onset of type 1 diabetes but rather manages an existing condition.

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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?

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