A nurse is having difficulty eliciting a patellar reflex. Which of the following would be most appropriate for the nurse to have the client do?

Lock the fingers together and pull against each other.

Squeeze a thigh with the opposite hand.

Stretch the arms over the head.

Clench the jaw tightly

Answer and Explanation

The Correct Answer is A

A.   This maneuver is intended to engage other muscle groups and increase overall muscle tone. It can help facilitate the patellar reflex by increasing muscle tension and sensitivity. This technique can enhance the reflex response by engaging the client in a physical action that might make the reflex more pronounced.
B.   Squeezing the thigh might create discomfort or involuntary muscle contraction, which could interfere with the reflex response. It is not a recommended technique for eliciting the patellar reflex and may not have a significant effect on reflex assessment.
C.   Stretching the arms over the head does not directly influence the patellar reflex. Reflexes are typically assessed in a relaxed state, and this action might not be relevant for improving the patellar reflex response.
D.   Clenching the jaw might increase overall muscle tone temporarily, but it does not directly impact the patellar reflex. This technique is less likely to influence the patellar reflex compared to techniques that engage lower body muscle groups.

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Correct Answer is D

Explanation

A. Concentration refers to the ability to focus on a specific task or thought for a period of time. While concentration is important for cognitive functioning, it is not the specific skill being assessed when interpreting the meaning of a proverb.
B. Attention is the ability to focus and direct mental resources towards a specific task or stimulus. While attention is necessary for understanding and processing information, the task of interpreting a proverb is more related to higher-level cognitive processes rather than just the ability to maintain focus.
C. Affect refers to the emotional state or mood of a person. It involves how emotions are expressed and experienced. Assessing affect involves observing the client’s emotional responses, not their ability to interpret abstract concepts. Therefore, affect is not the focus of this assessment.
D. Abstract reasoning is the ability to understand and interpret concepts and ideas that are not directly observable or tangible. It involves thinking beyond concrete facts to understand underlying meanings, patterns, and relationships. Interpreting a proverb, which involves understanding a figurative meaning rather than a literal one, is a test of abstract reasoning. The ability to grasp the deeper meaning behind “A penny saved is a penny earned” reflects the client's capacity for abstract reasoning.

A. Coma B. Lethargy C. Obtunded D. Stupor

Correct Answer is B

Explanation

A. Coma is a state of profound unconsciousness where the patient cannot be awakened and does not respond to any stimuli, including verbal commands or physical stimuli.

B. Lethargy is characterized by a state of drowsiness or fatigue where the patient may fall asleep easily but can be roused to respond appropriately when stimulated. The patient shows decreased alertness but is still capable of engaging with stimuli.
C. Obtunded refers to a state where the patient has reduced alertness and responsiveness. They may respond slowly and require increased stimulation to achieve a response. They are less aware of their environment and have dulled senses.
D. Stupor is a state of near-unconsciousness where the patient can only be awakened by vigorous or painful stimuli. They may not respond to verbal commands but may show some response to more intense stimuli.

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A nurse is having difficulty eliciting a patellar reflex. Which of the following would be most appropriate for the nurse to have the client do?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During an assessment, the nurse asks a client to explain what the following means: "A penny saved is a penny earned." The nurse is assessing which of the following?

Correct Answer is D

Explanation

A client opens the eyes and answers questions however falls back asleep within seconds. How should the nurse document this assessment finding?

Correct Answer is B

Explanation

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