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 A
Explanation
Choice A: This response indicates an understanding of the need to avoid high- risk activities that could worsen the condition or cause injury to the affected leg, which is appropriate after acute osteomyelitis.
Choice B: While exercise is important, it should be done under medical guidance, especially after a significant illness like acute osteomyelitis.
Choice C: Resuming normal activities may not be appropriate immediately, and the level of activity should be determined by the healthcare provider.
Choice D: Keeping the leg immobile is not typically recommended as it can lead to muscle atrophy and other complications.
Correct Answer is A
Explanation
Choice A: Increased Ca+ influx with sympathetic stimulation that raises the heart rate is a manifestation of sympathetic innervation. Sympathetic activation leads to the release of norepinephrine, which enhances the influx of calcium ions (Ca+) into cardiac muscle cells, resulting in increased contractility and heart rate.
Choice B: Sympathetic activation does increase the inotropic effect (contractility) of the heart, but it is primarily mediated by the increased influx of calcium ions (Ca+).
Choice C: Sympathetic activation does not decrease dromotrophy (conduction speed). Instead, it can increase the conduction speed through the cardiac conduction system.
Choice D: Increased Na+ influx with sympathetic stimulation does not reduce pacemaker firing; instead, it contributes to the enhanced excitability and automaticity of cardiac cells.
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.