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: A practical nurse assisting the healthcare provider with a lumbar puncture at the bedside is a high-risk procedure that requires direct supervision by an RN or a qualified healthcare provider. The RN should ensure the procedure is performed safely and effectively, as it involves potential risks and complications.
Choice B: Starting a transfusion of packed red blood cells is an important nursing intervention, but it does not necessarily require direct supervision by an RN, especially if the nurse has been trained and is competent in administering blood transfusions.
Choice C: Weighing an obese bedfast client using a bed scale is a routine nursing task that can be performed by unlicensed assistive personnel (UAP) with appropriate training. While the RN should ensure that the UAP is properly trained, direct supervision may not be required for this specific task.
Choice D: Accessing a client's implanted port to start an infusion of Ringer's Lactate is a nursing task that can be performed by a graduate nurse, especially if they have received appropriate training and competency validation. Direct supervision by an RN may not be necessary in this situation.
Correct Answer is B
Explanation
Choice A: Teaching clients about the potential side effects of antipsychotic drugs is important, but it is not the most critical aspect of medication administration policy. Monitoring for side effects and adverse reactions is typically the responsibility of healthcare providers and nursing staff.
Choice B: Monitoring all clients receiving antipsychotic drugs for indications of tardive dyskinesia is a crucial standard to include in the policy. Tardive dyskinesia is a serious side effect associated with long-term use of antipsychotic medications, and early detection and intervention are essential to prevent its progression.
Choice C: Ensuring that all clients treated with antipsychotic drugs receive prompt renewals as needed is important for continuity of care, but it is not the primary focus of a policy for administering antipsychotic medications.
Choice D: Documenting all client therapeutic serum levels related to antipsychotic medications is relevant but may not apply to all clients receiving these medications. Monitoring for side effects and adverse reactions is generally more universally applicable and critical to patient safety.
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