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 C

Explanation

Choice A: Cheese products are not part of a vegan diet as they come from animal sources (dairy).

Choice B: Egg white products are also not part of a vegan diet as they come from animal sources (eggs).

Choice C: Soybean products, such as tofu and tempeh, are commonly recommended for vegans to enhance their nutritional intake. These products are rich in protein, calcium, and other nutrients and can be used as meat or dairy substitutes in various recipes.

Choice D: Shellfish products are not part of a vegan diet as they come from animal sources (shellfish).

A. Hematocrit. B. Albumin and protein. C. White blood cell count (WBC). D. Electrolytes.

Correct Answer is D

Explanation

Choice A: Hematocrit is a measure of the proportion of blood volume occupied by red blood cells. While it can provide information about anemia or dehydration, it is not typically the first consideration in evaluating numbness and tingling in the extremities.

Choice B: Reviewing albumin and protein levels may be important for assessing overall nutritional status and potential causes of neuropathy but is not the immediate priority when a client reports numbness and tingling in the extremities.

Choice C: White blood cell count (WBC) is important for assessing immune function and the presence of infections. However, it is not typically the primary focus when evaluating numbness and tingling in the extremities.

Choice D: Electrolytes, such as serum sodium and potassium levels, are crucial to review when a client reports numbness and tingling in the extremities. Abnormal electrolyte levels can lead to neurological symptoms, and a review of electrolyte levels can help identify potential causes.

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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

The nurse is planning a nutrition class for vegans. Which food should the nurse encourage to be combined with other foods to enhance the nutritional intake in the vegan diet?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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