A nurse is assessing deep tendon reflexes in a client who sustained a spinal cord injury 5 days ago. The nurse can elicit a mild response to a tap on the patella. What is the nurse's in-terpretation of this finding?

A. There is a gradual response of all the nerves and muscles.
B. It is too early to tell how extensive the injury is at this time.
C. The injury has resulted in only temporary spinal cord dysfunction.
D. The spinal shock phase of the injury is over.


D
The patellar reflex is an ipsilateral response of lower motor neurons. It can remain intact even when the spinal cord is completely severed because this reflex does not require the input of upper motor neurons or interneurons. Return of reflexes is a sign of spinal shock resolution. Note that spinal shock is not neurogenic shock.

Nursing

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