The nurse is assessing the reflexes of a 35-year-old client who came to the clinic for an annual physical exam. When the nurse strikes the patellar tendon, there is no response. What action should the nurse take next?
The nurse is assessing the reflexes of a 35-year-old client who came to the clinic for an annual physical exam. When the nurse strikes the patellar tendon, there is no response. What action should the nurse take next?
Test the other reflexes later in the exam.
Distract the client by instructing him to pull on his fingers.
Instruct the client to see a neurologist as soon as possible.
Record the patellar reflex as a zero.
The Correct Answer is A
Choice A: When a reflex response is not elicited, it is important to proceed with testing other reflexes later in the exam to assess the overall neurological status. A single absence of a reflex may not be indicative of a problem, so further assessment is needed.
Choice B: Distracting the client by instructing him to pull on his fingers is not an appropriate action when assessing reflexes.
Choice C: Instructing the client to see a neurologist as soon as possible based solely on the absence of one reflex would be premature. Further assessment is needed to determine the significance.
Choice D: Recording the patellar reflex as a zero without further assessment would not provide a comprehensive evaluation of the client's reflexes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: Impaired cognition is not a common manifestation of Cushing's syndrome. Cushing's syndrome is primarily characterized by hormonal imbalances and physical symptoms.
Choice B: Memory loss is not a common manifestation of Cushing's syndrome. The syndrome is more associated with hormonal and metabolic disturbances.
Choice C: Mood alterations, including irritability, anger, and emotional instability, are common manifestations of Cushing's syndrome. These mood changes can be attributed to the hormonal imbalances and physiological stress associated with the condition.
Choice D: Hearing loss is not a recognized symptom of Cushing's syndrome. Mood alterations and physical changes are more typical.
Correct Answer is B
Explanation
Choice A: Obliterating the entry and inserting the correct information may make the charting less clear and may not be considered a best practice in documentation.
Choice B: Drawing one line through the entry and inserting the correct information is a common method for correcting errors in paper documentation. It maintains clarity while indicating that an error was made and corrected.
Choice C: Charting the correct information in the next column may lead to confusion and does not clearly indicate that an error was made and corrected.
Choice D: Notifying the charge nurse that the entry needs to be revised may be necessary in some situations but is not the first step in correcting a charting error. The error should be corrected at the point of documentation.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.