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

Explanation

A. Double room with a 4-month-old who has RSV: This is the best option. RSV is highly contagious but children with the same infection may be cohorted (roomed together) to minimize transmission to other clients and conserve private rooms for uninfected or immunocompromised children.
B. Private room with negative air pressure: Negative pressure rooms are reserved for airborne infections like tuberculosis, not RSV, which is spread through contact and droplets.
C. Private room furthest from the nurses station: While a private room is acceptable, location relative to the nurses station is not a priority. Cohorting with another RSV-positive child is equally effective.
D. Double room with a 6-month-old on droplet precautions: Unless the other child also has confirmed RSV, placing them together risks spreading the virus if their infections differ. Droplet precautions alone do not confirm the same diagnosis.

A. Partner with a major pharmaceutical company to provide nebulizers at reduced cost to inner-city children. B. Offer free asthma screening to children at a health fair sponsored by a local hospital. C. Inform the city council of the need to strengthen the city's air pollution ordinances. D. Refer parents of preschoolers with asthma to a support group sponsored by the American Lung Association.

Correct Answer is C

Explanation

Choice A: Partnering with a major pharmaceutical company to provide nebulizers at reduced cost to inner-city children is an example of a secondary prevention strategy aimed at managing asthma symptoms and exacerbations. It does not address primary prevention, which focuses on preventing the development of the condition in the first place.

Choice B: Offering free asthma screening to children at a health fair is a secondary prevention strategy aimed at early detection and management of existing asthma cases. It does not address primary prevention.

Choice C: Informing the city council of the need to strengthen the city's air pollution ordinances is a primary prevention strategy. It aims to address environmental factors (such as air pollution) that can contribute to the development of asthma in children. By reducing exposure to environmental triggers, the goal is to prevent new cases of asthma from occurring.

Choice D: Referring parents of preschoolers with asthma to a support group sponsored by the American Lung Association is a secondary prevention strategy aimed at providing support and education to

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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

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Correct Answer is A

Explanation

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Correct Answer is C

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