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

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.

A. Eat a high protein diet three times a day. B. Restrict sodium rich foods and excessive oral fluids. C. Follow low carbohydrate diet with low glycemic index foods. D. Avoid foods high in potassium.

Correct Answer is B

Explanation

Choice A: A high protein diet is generally not recommended for clients with glomerulonephritis, as it can put additional strain on the kidneys.

Choice B: In glomerulonephritis, there is impaired kidney function, and sodium and fluid restrictions are often necessary to manage fluid balance and blood pressure.

Therefore, the nurse should instruct the client to restrict sodium-rich foods and excessive oral fluids.

Choice C: A low carbohydrate diet with low glycemic index foods is not a specific dietary recommendation for managing glomerulonephritis.

Choice D: Dietary potassium restriction may vary depending on the individual client's potassium levels and needs, so it should be determined by the healthcare provider. It is not a blanket recommendation for all clients with glomerulonephritis.

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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 client tells the nurse about taking a variety of herbal products, including milk thistle, and has lost about thirty pounds over the last month. Which action should the nurse implement?

Correct Answer is B

Explanation

A client with glomerulonephritis is preparing for discharge and asks the nurse which kind of diet to follow upon returning home. Which dietary teaching should the nurse include in the discharge instructions?

Correct Answer is B

Explanation

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