Author Question: The nurse has assessed a client and notes diminished reflexes. How would the nurse document this ... (Read 54 times)

BRWH · **on:** Jun 25, 2018

The nurse has assessed a client and notes diminished reflexes. How would the nurse document this finding in the medical record?

1. 4+/0 - 4+.
2. 3+/0 - 4+.
3. 2+/0 - 4+.
4. 1+/0 - 4+.

Question 2

The nurse is assessing cranial nerve XI (spinal accessory). Which statements would the nurse say to the client in order to complete this assessment?

1. Shrug your shoulders and turn your head against my hand.
2. Stick out your tongue and move it from side to side.
3. Taste these foods and decide which is sweet and which is sour.
4. Smell these items and identify what they are.

tandmlomax84 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Correct Answer: 4
Evaluation of reflex responses uses a scale from 0 to 4+. 0 = no response; 1+ = diminished; 2+ = normal; 3+ = brisk, above normal; 4+ = hyperactive.

Answer to Question 2

Correct Answer: 1
The spinal accessory nerve (cranial nerve XI) controls shoulder and neck movements. The examiner planning to test this nerve should ask the client to shrug the shoulders and turn the head. The hypoglossal nerve (cranial nerve XII) is responsible for the movement of the tongue. The facial nerve (cranial nerve VII) is responsible for the sense of taste and symmetrical facial movements. Smell is controlled by the olfactory nerve (cranial nerve I).