The nurse is assessing the patellar reflex on a client and ...

[deesands]

The nurse is assessing the patellar reflex on a client and obtains no reflexive activity. The client is alert and oriented. Which action by the nurse is the most appropriate?
 
  1. Document the findings as normal.
  2. Notify the healthcare provider immediately.
  3. Look at the medication records for central nervous system depressants.
  4. Retest the reflex after having the client use distraction during the exam.

Question 2

The nurse is preparing to conduct a focused interview on a client who is experiencing back pain. Which questions will the nurse include in this focused interview? Select all that apply.
 
  1. How long have you been experiencing this pain?
  2. What activities seem to increase your pain?
  3. Are your children physically active?
  4. What things do you do to relieve your pain?
  5. Are you receiving worker's compensation?

[mk6555]

Answer to Question 1

Correct Answer: 4
Reflexes are stimulus-response activities of the body. They are fast, predictable, unlearned, innate, and involuntary reactions to stimuli. The individual is aware of the results of the reflex activity and not the activity itself. The reflex activity may be simple and take place at the level of the spinal cord, with interpretation at the cerebral level. Reflex activity is recorded using a 4-point scale. Normal reflexes are listed as a 2+. The absence of the patellar reflex is not normal. Before concluding that a reflex is absent or diminished the test should be repeated. The client should be encouraged to relax. It may be necessary to distract the client to achieve relaxation of the muscle before striking the tendon. Documentation of the reflexes as normal is not appropriate, as a score of 0 is not normal. There is no immediate need to notify the healthcare provider. Medications should eventually be reviewed to determine any impact on the nervous system but this action does not precede attempting to reassess the reflexes.

Answer to Question 2

Correct Answer: 1, 2, 4