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 C

Explanation

A. Observe the scrotum for swelling: Scrotal swelling might indicate issues such as a hydrocele, varicocele, or hernia, but it is not directly linked to urinary difficulties like nocturia or trouble initiating urination. It’s not the most targeted assessment in this context.

B. Inspect the urethral meatus for discharge: Discharge can suggest infection, such as urethritis or sexually transmitted infections, but it’s not a common finding in cases of nocturia and hesitancy typically associated with prostate issues.

C. Question the client about related symptoms: Asking about related symptoms such as weak stream, dribbling, incomplete emptying, or urgency helps the nurse assess for conditions like benign prostatic hyperplasia (BPH). This focused history provides critical insight into urinary function and guides further evaluation or referral.

D. Palpate the inguinal area for a bulge: This checks for inguinal hernias, which can cause groin discomfort but are not typically linked with urinary hesitancy or nocturia. It's a useful exam, but not the most relevant first step based on the symptoms presented.

A. Repeat vocalizing the letter "E" while the thorax is auscultated. B. Whisper "one, two, three" in sequence during auscultation of the thorax. C. Repeat the number "99" during a systematic auscultation of the thorax. D. Breathe in and out while all lobes of both lungs are auscultated.

Correct Answer is A

Explanation

A. Repeat vocalizing the letter "E" while the thorax is auscultated: Egophony is assessed by having the client say "E" while the nurse auscultates the chest. In the presence of lung consolidation, such as in a lung abscess, the "E" sound may be auscultated as an "A"—a finding known as the "E-to-A" change, which is a hallmark of egophony.

B. Whisper "one, two, three" in sequence during auscultation of the thorax: This technique is used to assess whispered pectoriloquy, not egophony. It helps detect areas of lung consolidation if whispered words are heard clearly through the stethoscope.

C. Repeat the number "99" during a systematic auscultation of the thorax: This test is used to assess bronchophony, increased loudness and clarity of spoken words, another sign of lung consolidation. Clear transmission of "99" may suggest fluid or consolidation in the lungs.

D. Breathe in and out while all lobes of both lungs are auscultated: This is a standard part of respiratory assessment but is not specific for egophony. It helps detect abnormal breath sounds like wheezes, crackles, or diminished sounds, not vocal resonance changes.

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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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