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.

Answer and Explanation

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.

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Correct Answer is ["A","C"]

Explanation

Choice A: Cooked cereal can be used as part of a gastrostomy tube feeding regimen for clients who require enteral nutrition.

Choice B: Lettuce is not typically used in gastrostomy tube feedings as it may not be well-tolerated in liquid form.

Choice C: Clear fat-free broth can be used as part of a gastrostomy tube feeding regimen for clients who require enteral nutrition.

Choice D: Brussels sprouts and nuts are not typically used in gastrostomy tube feedings as they may not be well-tolerated in liquid form.

A. Perform a fundal massage. B. Draw blood for hemoglobin and hematocrit. C. Obtain a complete obstetrical history. D. Inspect the perineum for lacerations.

Correct Answer is A

Explanation

Choice A: Performing a fundal massage is the first priority in this situation to assess and manage uterine tone and prevent postpartum hemorrhage.

Choice B: Drawing blood for hemoglobin and hematocrit can be important but is not the immediate priority when the client has just delivered outside the hospital.

Choice C: Obtaining a complete obstetrical history is important but can be done after addressing the immediate postpartum concerns.

Choice D: Inspecting the perineum for lacerations is also important but should be done after addressing uterine tone and hemorrhage prevention.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When conducting diet teaching for a client who is on a gastrostomy tube feeding, which foods should the nurse encourage the client use? (Select all that apply.)

Correct Answer is ["A","C"]

Explanation

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Correct Answer is A

Explanation

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