The nurse is assessing the patellar reflex on a client and obtains no reflexive activity. The client is alert and oriented. The nurse should do which of the following in this situation?
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.
4
Rationale 1: 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. 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.
Rationale 2: There is no immediate need to notify the healthcare provider.
Rationale 3: 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. Medications should eventually be reviewed to determine any impact on the nervous system but this action does not precede attempting to reassess the reflexes.
Rationale 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.
You might also like to view...
A 1-month-old infant has a head measurement of 34 cm and has a chest circumference of 32 cm. Based on the interpretation of these findings, the nurse would:
a. Refer the infant to a physician for further evaluation. b. Consider these findings normal for a 1-month-old infant. c. Expect the chest circumference to be greater than the head circumference. d. Ask the parent to return in 2 weeks to re-evaluate the head and chest circumferences.
When team members or a nursing unit work together and make decisions as a group, this team demonstrates what type of environment?
1. Autocratic 2. Collaborative 3. Professional 4. Relaxed
The nurse is assessing a newly admitted older patient for modifiable risk factors for stroke development. The nurse would include teaching about which findings?
1. Blood pressure is consistently above 95 diastolic. 2. The patient has had two recent hospital admissions to treat dehydration. 3. The patient reports drinking a glass of wine with dinner every evening. 4. The patient uses smokeless tobacco. 5. Testing has previously indicated the patient has hypercholesterolemia.
When assisting the health care provider with removal of the chest tube, which instruction should the nurse provide to the client during this procedure?
1. Breathe normally 2. Hold still 3. Hold breath 4. Cough