The nurse is assessing the ankle reflex in a patient with hyperactive reflexes. When the patient's foot is abruptly dorsiflexed, it continues to "beat" 2 to 3 times before setting into a resting position
The nurse would document this finding as which of the following?
A) Rigidity
B) Flaccidity
C) Clonus
D) Ataxia
Ans: C
Chapter: 60
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 4
Patient Needs: A-1
Feedback: When reflexes are very hyperactive, a phenomenon called clonus may be elicited. If the foot is abruptly dorsiflexed, it may continue to "beat" two to three times before it settles into a position of rest. Rigidity is an increase in muscle tone at rest characterized by increased resistance to passive stretch. Flaccidity is lack of muscle tone. Ataxia is the inability to coordinate muscle movements, resulting in difficulty walking, talking, and performing self-care activities.
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