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 C
Explanation
Choice A: Permethrin cream may cause temporary itching and skin irritation as it works to eliminate the scabies mites. Instructing the client to remove the cream immediately if pruritis occurs is not necessary; it is a common and expected side effect during treatment.
Choice B: Reapplication of permethrin is not typically done in seven days unless directed by the healthcare provider. A single application is often effective in treating scabies.
Choice C: Showering or bathing 8 to 14 hours after permethrin treatment is a common instruction to remove the cream and dead mites. This is an important part of the treatment process.
Choice D: Avoiding areas between fingers and toes during application is not necessary, as permethrin is generally safe for use on these areas. However, it should not be applied to the face or near the eyes.
Correct Answer is C
Explanation
Choice A: This is not specifically related to the side effects of phenytoin.
Choice B: This is not directly related to the common side effects of phenytoin, which primarily affect the oral cavity.
Choice C: Phenytoin (Dilantin) is known to cause gingival hyperplasia (enlargement of the gums) as a common side effect. The nurse should regularly inspect the client's mouth to monitor for this adverse effect.
Choice D: This is not specifically relevant to monitoring for phenytoin's side effects.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.