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. Nasal polyps: Nasal polyps are soft, noncancerous growths in the nasal passages or sinuses, often linked to chronic inflammation, asthma, or allergies. They do not cause sore throat, fever, or difficulty swallowing, and are not associated with strep pharyngitis.

B. Laryngeal polyps: Laryngeal polyps typically present with hoarseness due to vocal cord involvement but are not associated with high fever, painful swallowing, or infections like streptococcal pharyngitis. They are usually non-infectious and develop gradually.

C. Foreign body obstruction: A foreign body obstruction causes sudden onset symptoms such as choking, coughing, or respiratory distress. This does not align with a progressive infectious presentation like fever and muffled voice, which suggests a localized infection.

D. Peritonsillar abscess: A peritonsillar abscess is a common complication of untreated or severe streptococcal pharyngitis. It presents with high fever, difficulty swallowing (dysphagia), muffled or "hot potato" voice, and unilateral throat pain due to pus collection near the tonsils.

A. A 24 hour diet history. B. Status of current appetite. C. History of a recent weight loss. D. Condition of hair, nails, and skin.

Correct Answer is D

Explanation

A. A 24-hour diet history: While a 24-hour diet history can provide some information about recent food intake, it may not accurately reflect long-term nutritional status. Nutritional deficiencies often develop over time, and a single day's intake might not capture overall dietary patterns.

B. Status of current appetite: Appetite can be influenced by many factors, including illness, medications, or psychological conditions. While it is an important consideration in a nutritional assessment, it alone does not give the most reliable insight into an individual’s overall nutritional status.

C. History of a recent weight loss: Recent weight loss could indicate malnutrition or a medical issue, but it doesn't provide a complete picture of an individual's overall nutritional health. Long-term assessments, such as changes in body composition, would give more insight.

D. Condition of hair, nails, and skin: The condition of hair, nails, and skin is a key indicator of nutritional status, as these tissues are directly affected by nutrient deficiencies. Signs such as brittle nails, thinning hair, or dry, flaky skin can reflect deficiencies in vitamins, minerals, and overall nutrition, providing a more comprehensive view of an individual's nutritional health.

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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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