The nurse assesses brisk reflexes in a client. The nurse would document this finding as which of the following?

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Use tangential lighting: Tangential lighting is not typically used for assessing heart impulses; it is more useful for examining surface characteristics of the skin.

B. Assist the client to a standing position: The client should be in a supine or semi-recumbent position for accurate inspection of apical heart impulses, not standing.

C. Use perpendicular lighting: Perpendicular lighting is crucial for accurately visualizing apical heart impulses, as it helps to clearly observe the movement of the heart against the chest wall.

D. Focus a penlight on the client's chest: While a penlight can be used in physical assessments, perpendicular lighting is more effective for clearly seeing the apical heart impulses.

A. It filters harmful substances from the body. B. It drains capillary blood from the circulation. C. It produces protective antibodies. D. It manufactures T lymphocytes.

Correct Answer is A

Explanation

A. It filters harmful substances from the body: The lymphatic system plays a crucial role in filtering lymph fluid and removing harmful substances, such as pathogens and toxins, through lymph nodes.

B. It drains capillary blood from the circulation: The lymphatic system does not directly drain capillary blood; instead, it collects interstitial fluid and returns it to the bloodstream.

C. It produces protective antibodies: Antibodies are produced by B lymphocytes in the immune system, not directly by the lymphatic system itself.

D. It manufactures T lymphocytes: While the lymphatic system is involved in the maturation and function of T lymphocytes, their manufacture occurs in the bone marrow and thymus rather than the lymphatic system itself.

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The nurse assesses brisk reflexes in a client. The nurse would document this finding as which of the following?

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Naxlex Comprehensive Predictor Exams

The nurse is planning to inspect a client's apical heart impulses. What should the nurse do to ensure an accurate assessment of this organ?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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