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 ["B","C","D"]

Explanation

Choice A: Closing the blinds to darken the room may not be the immediate priority during a seizure. Ensuring the safety and well-being of the child takes precedence.

Choice B: Asking the mother to release the child is an important action. It is essential to prevent any further physical restraint during a seizure, as it can cause harm to the child or the person attempting to restrain them.

Choice C: Monitoring the child's airway and tongue is crucial during a seizure to prevent any obstruction that could interfere with breathing. It is important to ensure the child does not choke on saliva or vomit.

Choice D: Administering an anticonvulsant medication may be necessary in certain situations, especially if the seizure persists or is prolonged. The healthcare provider's orders should be followed for the administration of appropriate medications

Choice E: Placing pillows inside the side rails is not a relevant intervention during a seizure. The focus should be on ensuring the child's safety, assessing their airway, and providing appropriate care during the seizure.

A. Praise the client for the successful weight loss using the natural herbs. B. Tell the client to schedule an appointment with a healthcare provider. C. Advise the client to begin taking a multivitamin daily. D. Document the client's reason for using the herb.

Correct Answer is B

Explanation

Choice A: Praising the client for weight loss without knowing the underlying cause may not be appropriate. Rapid and unexplained weight loss can be a sign of underlying health issues.

Choice B: Advising the client to schedule an appointment with a healthcare provider is the most appropriate action. Rapid and unexplained weight loss should be evaluated by a healthcare professional to identify any potential underlying health concerns.

Choice C: Advising the client to begin taking a multivitamin daily does not address the underlying cause of the weight loss and may not be the most appropriate action.

Choice D: Documenting the client's reason for using the herb is important but should be accompanied by further evaluation and intervention by a healthcare provider due to the significant weight loss.

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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

A male child is being prepared for a computed tomography (CT) scan when he begins to have a tonic clonic seizure. His mother is hysterical and is trying to hold the child down. Which action(s) should the nurse take? (Select all that apply.)

Correct Answer is ["B","C","D"]

Explanation

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Correct Answer is B

Explanation

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