The nurse is assessing the reflexes of a 35-year-old client who came to the clinic for an annual physical exam. When the nurse strikes the patellar tendon, there is no response. What action should the nurse take next?
The nurse is assessing the reflexes of a 35-year-old client who came to the clinic for an annual physical exam. When the nurse strikes the patellar tendon, there is no response. What action should the nurse take next?
Test the other reflexes later in the exam.
Distract the client by instructing him to pull on his fingers.
Instruct the client to see a neurologist as soon as possible.
Record the patellar reflex as a zero.
The Correct Answer is A
Choice A: When a reflex response is not elicited, it is important to proceed with testing other reflexes later in the exam to assess the overall neurological status. A single absence of a reflex may not be indicative of a problem, so further assessment is needed.
Choice B: Distracting the client by instructing him to pull on his fingers is not an appropriate action when assessing reflexes.
Choice C: Instructing the client to see a neurologist as soon as possible based solely on the absence of one reflex would be premature. Further assessment is needed to determine the significance.
Choice D: Recording the patellar reflex as a zero without further assessment would not provide a comprehensive evaluation of the client's reflexes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A: A complete blood count (CBC) is important for monitoring various aspects of the blood, including the number of red blood cells, white blood cells, and platelets. While important for assessing overall health, a CBC is not the primary laboratory finding used to assess the effectiveness of warfarin in managing atrial fibrillation.
Choice B: Serum troponin levels are typically measured to assess cardiac muscle damage, such as in myocardial infarction (heart attack). They are not the primary indicator for assessing the effectiveness of warfarin in atrial fibrillation.
Choice C: Creatinine clearance is a measure of kidney function and is not the primary laboratory finding used to evaluate the effectiveness of warfarin.
Choice D: Prothrombin time (PT) is the most relevant laboratory finding for monitoring the effectiveness of warfarin in clients with atrial fibrillation. Warfarin's therapeutic effect is primarily assessed through PT measurements, with the goal of maintaining the client's international normalized ratio (INR) within a specific target range to prevent excessive bleeding or clotting.
Correct Answer is C
Explanation
Choice A: Changing the normal saline to a keep-open rate (KVO) is not appropriate in this situation, as the client has specific fluid orders that need to be followed, and a KVO rate would not provide the prescribed maintenance fluids.
Choice B: Increasing the rate of the present normal saline infusion to 75 drops per minute would not meet the prescription for 0.9% normal saline at 75 ml/hour.
Adjusting the rate this way would require an infusion pump.
Choice C: Leaving the normal saline at the current rate until an infusion pump is available is the most appropriate action. It ensures that the client continues to receive fluids at the ordered rate until the necessary equipment is in place.
Choice D: Switching the saline to Lactated Ringer's solution infusing at 75 drops per minute would not meet the prescribed rate for the normal saline solution. The nurse should follow the specific orders provided.
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