The nurse assesses brisk reflexes in a client. The nurse would document this finding as which of the following?
4+
2+
1+
3+
The Correct Answer is D
A. 4+: This indicates very brisk reflexes with possible clonus, which is more than just brisk reflexes.
B. 2+: This indicates normal reflexes, not brisk.
C. 1+: This indicates diminished or hypoactive reflexes, not brisk.
D. 3+: This indicates brisk reflexes, which are faster than normal but without evidence of clonus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Tuning fork: A tuning fork is used in auditory assessments, such as hearing tests, to evaluate hearing loss and bone conduction.
B. Stethoscope: While a stethoscope is essential for auscultation of heart and lung sounds, it is not used for examining the ears.
C. Ophthalmoscope: An ophthalmoscope is used for examining the eyes, not the ears.
D. Tongue depressor: A tongue depressor is used for examining the mouth and throat, not the ears.
Correct Answer is B
Explanation
A. S2: This sound, also known as "dub," occurs during diastole when the semilunar valves close.
B. S1: This sound, also known as "lub," occurs during systole when the atrioventricular valves close, marking the beginning of systole.
C. S4: This sound is an abnormal heart sound associated with late diastole, not systole.
D. S3: This sound is associated with early diastole and is typically related to rapid ventricular filling, not systole.
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