The nurse observes generalized weakness and diminished deep tendon reflexes on the right side of an older adult client who has a history of a cerebrovascular accident. Which deep tendon reflex response should the nurse document to support the client's clinical assessment?

Right side deep tendon reflex 2+.

Right side deep tendon reflex 0.

Right side deep tendon reflex 4+.

Right side deep tendon reflex 1+.

Answer and Explanation

The Correct Answer is D

A. Right side deep tendon reflex 2+: A 2+ reflex is considered normal and would not correlate with the nurse’s observation of diminished reflexes. Documenting 2+ would fail to reflect the neurological deficit noted in the assessment.

B. Right side deep tendon reflex 0: A 0 reflex indicates complete absence of a response, suggesting flaccid paralysis or severe lower motor neuron damage. The nurse observed diminished reflexes, not absent, so 0 would overstate the impairment.

C. Right side deep tendon reflex 4+: A 4+ reflex indicates hyperreflexia, often associated with upper motor neuron lesions, not weakness and diminished reflexes. This would contradict the nurse’s findings of decreased neuromuscular activity on the right side.

D. Right side deep tendon reflex 1+: A 1+ rating represents diminished or hypoactive reflexes, which aligns with the nurse’s findings of generalized weakness and reduced deep tendon activity. This accurately reflects the likely residual neurological effects post-CVA.

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Correct Answer is D

Explanation

A. Perform passive range of motion and compare the findings: While assessing range of motion may help identify functional limitations or stiffness, it does not directly address the issue of leg asymmetry, which may be due to structural differences rather than functional impairment.

B. Instruct client to walk across room and observe the gait: Gait analysis is important for evaluating mobility and balance, but it doesn't directly address the underlying cause of leg asymmetry, especially if the asymmetry is due to a structural or anatomical issue rather than a functional one.

C. Compare measured circumferences of each extremity joint: Comparing circumferences can help identify swelling or muscle wasting, but it does not address leg length discrepancies or structural differences that could be contributing to the asymmetry.

D. Measure the length of each leg and document the findings: Measuring leg length is the most appropriate action to assess for a potential leg length discrepancy, which is a common cause of asymmetry. This will help determine if the asymmetry is structural (due to bone length differences) or due to other causes.

A. Record this normal finding in the assessment record. B. Ask the client about any localized tenderness at the site. C. Auscultate the lymph node for the presence of a bruit. D. Cover the inflamed area and notify the healthcare provider.

Correct Answer is B

Explanation

A. Record this normal finding in the assessment record: An enlarged lymph node is not a normal finding and should not be recorded as such. It may indicate an infection, inflammation, or other underlying conditions. Further investigation is required to determine the cause of the enlargement.

B. Ask the client about any localized tenderness at the site: Assessing tenderness in the enlarged lymph node helps the nurse gather information about the potential cause. Tender lymph nodes are often associated with infections or inflammation, while non-tender nodes may indicate other issues, such as malignancy. This assessment is crucial in guiding further action.

C. Auscultate the lymph node for the presence of a bruit: A bruit is an abnormal sound that indicates turbulent blood flow and is typically heard over arteries, not lymph nodes. Auscultating a lymph node for a bruit is not relevant to this assessment.

D. Cover the inflamed area and notify the healthcare provider: While notifying the healthcare provider may be necessary later, the immediate priority is to assess the lymph node's characteristics, including tenderness and any other related symptoms, to guide appropriate action. Simply covering the area without further assessment would delay the necessary evaluation.

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The nurse observes generalized weakness and diminished deep tendon reflexes on the right side of an older adult client who has a history of a cerebrovascular accident. Which deep tendon reflex response should the nurse document to support the client's clinical assessment?

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