A client's patellar reflex is normal for the right side but diminished on the left. Using the scale for grading reflexes, how should the nurse document this finding?

Right knee +1; Left knee 0

Right knee +3; Left knee +2

Right knee +2; Left knee +1

Right knee +4; Left knee +3

Answer and Explanation

The Correct Answer is C

A) Right knee +1; Left knee 0: The scale for grading reflexes typically ranges from 0 to 4. A score of 0 indicates no reflex, which does not align with the description of having a diminished but not absent reflex. A score of +1 suggests a reduced but present reflex, which would be appropriate for a diminished reflex on the left side.

B) Right knee +3; Left knee +2: A score of +3 indicates an exaggerated or brisk reflex, while +2 denotes a normal reflex. Since the right knee reflex is normal, it should be documented as +2. A diminished reflex on the left side is more accurately reflected by a score of +1, not +2.
C) Right knee +2; Left knee +1: This is the most accurate documentation. A score of +2 denotes a normal reflex, which applies to the right knee. A score of +1 reflects a diminished reflex, which is appropriate for the left knee where the reflex is present but reduced.
D) Right knee +4; Left knee +3: A score of +4 represents a very brisk or hyperactive reflex, which is not consistent with a normal finding. Similarly, a score of +3 would indicate an exaggerated reflex, which does not fit the description of the right knee being normal. The correct grading for a normal reflex is +2, and for a diminished reflex is +1.

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Correct Answer is D

Explanation

A. Pelvic examination: A pelvic examination is generally used to assess the reproductive organs in females rather than the prostate. It does not provide a direct assessment of the prostate gland in males.
B. Transillumination: Transillumination is a technique used to detect fluid-filled cysts or masses in areas such as the scrotum or breast. It is not used to assess the prostate gland.
C. Bladder percussion: Bladder percussion is used to assess bladder size and fullness, typically to diagnose conditions related to bladder dysfunction. It does not provide information about the prostate.
D. Digital rectal examination: A digital rectal examination (DRE) is the standard method used to assess the size, shape, and consistency of the prostate gland. It allows the clinician to feel the prostate through the rectal wall and is essential for evaluating prostate health.

A. the tricuspid area. B. Erb's point. C. the mitral area. D. the aortic area.

Correct Answer is D

Explanation

A) The tricuspid area: The tricuspid area is located at the lower left sternal border, around the 4th or 5th intercostal space. It is where the tricuspid valve sounds are best heard, not the area for auscultating the 2nd rib space.
B) Erb's point: Erb's point is located at the left sternal border in the 3rd intercostal space. It is a key area for auscultating both the aortic and pulmonic valves, as well as the mitral and tricuspid valves, but it is not associated with the right 2nd rib space.
C) The mitral area: The mitral area, also known as the mitral valve area, is located at the 5th intercostal space at the midclavicular line on the left side. This area is used for auscultating the mitral valve, not the right 2nd rib space.
D) The aortic area: The right 2nd rib space, also known as the 2nd intercostal space at the right sternal border, is the location where the aortic valve sounds are best auscultated. This area is used to listen to the aortic valve's closure and is the first location for cardiac auscultation.

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A client's patellar reflex is normal for the right side but diminished on the left. Using the scale for grading reflexes, how should the nurse document this finding?

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Naxlex Comprehensive Predictor Exams

Which of the following would the nurse expect to be done to assess the size of the prostate?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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