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 B

Explanation

A. "It doesn't take much activity before I'm out of breath.": This statement describes exertional dyspnea, which is shortness of breath with physical activity. It is often seen in heart or lung conditions but does not point to orthopnea, which occurs when lying flat.

B. "I sleep on three pillows at night.": Using multiple pillows to sleep is a compensatory behavior for orthopnea. Orthopnea is defined as difficulty breathing while lying flat, often related to heart failure and pulmonary congestion, and is relieved by elevating the head.

C. "I cough a lot at night and it keeps me up half the night.": Nocturnal coughing may indicate asthma, GERD, or postnasal drip. While it disrupts sleep, it does not clearly signify orthopnea, which is specifically related to positional shortness of breath.

D. "I have multiple attacks of wheezing almost daily.": Frequent wheezing attacks are more consistent with conditions like asthma or COPD. This symptom does not suggest orthopnea, which involves positional breathing difficulty, not episodic wheezing.

A. Ask questions in a vague, nonspecific format. B. Begin with questions that are less sensitive in nature. C. Share personal values to put the client at ease. D. Get the most difficult questions over with first.

Correct Answer is B

Explanation

A. Ask questions in a vague, nonspecific format: Vague questions can lead to unclear or incomplete answers and may confuse the client. A structured, clear, and respectful approach helps establish trust and encourages more honest responses over time.

B. Begin with questions that are less sensitive in nature: Starting with general or less personal questions helps build rapport and comfort with the client. Once trust is established, the client may feel more at ease discussing sensitive topics like family mental health history or personal concerns.

C. Share personal values to put the client at ease: Nurses should maintain professional boundaries during assessments. Sharing personal values may introduce bias or shift focus from the client’s needs and feelings, making it harder for them to open up.

D. Get the most difficult questions over with first: Jumping into sensitive or emotionally charged questions too early may make the client feel threatened or uncomfortable, especially if the topic is already distressing. A gradual approach helps promote openness and trust.

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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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Naxlex Comprehensive Predictor Exams

Which subjective assessment data supports the nurse's conclusion that a client is experiencing orthopnea?

Correct Answer is B

Explanation

Correct Answer is B

Explanation

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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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