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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

- A: Placing the 6-month-old with RSV in a double room with a 4-month-old who also has RSV is appropriate because they have the same infection, which reduces the risk of cross-infection with other pathogens. Cohorting patients with the same infectious disease is a common practice to prevent the spread to other patients.
- B: A private room with negative air pressure is typically used for patients who have airborne infections, which require a higher level of isolation to prevent the spread of diseases that are transmitted through the air. RSV is primarily spread through close contact and droplets, not through the air.
- C: A private room furthest from the nurse's station would not be ideal as it could delay care and observation for a young infant with a serious respiratory infection. Proximity to the nursing staff ensures prompt attention if the infant's condition changes.
- D: A double room with a 6-month-old on droplet precautions is not the best choice because it poses a risk of transmitting RSV to the other infant, who may not have RSV, leading to potential complications and further spread of infection within the unit.

Correct Answer is ["591"]

Explanation

One ounce is equivalent to 29.57 mL, so 12 ounces of coffee is equal to 354.84 mL. The cup of milk is usually measured as 8 ounces, which is 236.59 mL.

The oatmeal may also contain some fluid, but the amount is not given, so it cannot be counted.

Therefore, the total fluid intake at breakfast is 354.84 + 236.59 = 591.43 mL.

The nurse should document this value in the client's record, rounding it to the nearest whole number, which is 591 mL.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse-manager of a pediatric unit needs to assign a room for a 6-month-old diagnosed with respiratory syncytial virus (RSV). Which room assignment is best for the nurse-manager to make?

Correct Answer is A

Explanation

The nurse assesses a client's fluid intake at breakfast, which consisted of oatmeal, a cup of milk, and 12 ounces of coffee. How many mL should the nurse document in the client's record? (Enter numerical value only.)

Correct Answer is ["591"]

Explanation

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