While performing an assessment, the nurse taps a patient's knee ...

[ereecah]

While performing an assessment, the nurse taps a patient's knee and observes that the quadriceps muscle reflexively contracts. How should the nurse document this finding?
 
  a. Patellar reflex 2/5
  b. Patellar reflex 4/5
  c. Achilles reflex 2/5
  d. Achilles reflex 4/5

Question 2

Which behavior causes the nurse to report a positive Romberg test?
 
  a. The patient cannot keep his eyes closed.
  b. The patient cannot touch his nose with eyes closed.
  c. The patient complains of dizziness.
  d. The patient sways from side to side.

[kristenb95]

Answer to Question 1

A
This action describes a normal patellar reflex. The knee jerk, or patellar reflex, tests nerve path-ways to and from the spinal cord at the level of the second through fourth lumbar nerves. When the knee is tapped, the nerve that receives this stimulus sends an impulse to the spinal cord, where it is relayed to a motor nerve. This causes the quadriceps muscle at the front of the thigh to contract and to move the leg upward. This reflex, or simple reflex arc, involves only two nerves and one synapse. The leg begins to jerk up while the brain is just becoming aware of the tap on the knee. Reflexes are graded as follows: 0/5 = absent; 1/5 = weak response; 2/5 = normal; 3/5 = exaggerated response; and 4/5 = hyperreflexia with clonus.

Answer to Question 2

D
Romberg test evaluates equilibrium. The patient stands with eyes closed and feet only slightly apart. Swaying from side to side during the Romberg test is a positive sign for impaired balance.