The nurse has assessed a client and notes diminished reflexes. The nurse would correctly document which of the following?
1. 4+/0-4+
2. 3+/0-4+
3. 2+/0-4+
4. 1+/0-4+
1
Rationale 1: 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.
Rationale 2: 3+ - Evaluation of reflex responses uses a scale from 0 to 4+. 0 = no response; 1+ = diminished; 2+ = normal; 3+ = brisk, above normal; 4+ = hyperactive.
Rationale 3: 2+ - Evaluation of reflex responses uses a scale from 0 to 4+. 0 = no response; 1+ = diminished; 2+ = normal; 3+ = brisk, above normal; 4+ = hyperactive.
Rationale 4: 1+ - Evaluation of reflex responses uses a scale from 0 to 4+. 0 = no response; 1+ = diminished; 2+ = normal; 3+ = brisk, above normal; 4+ = hyperactive.
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