Nokea
A nurse is assessing reflexes in a patient with hyperactive reflexes. When the patients foot is abruptly dorsiflexed, it continues to beat two to three times before settling into a resting position. How would the nurse document this finding?
- A. Rigidity
- B. Flaccidity
- C. Clonus
- D. Ataxia
Correct Answer: C
Rationale: Clonus is characterized by rhythmic muscle contractions, such as foot beating after dorsiflexion, indicating hyperactive reflexes. Rigidity is increased muscle tone, flaccidity is lack of tone, and ataxia is uncoordinated movement.
You may also like to solve these questions
The nurse is admitting a patient to the unit who is diagnosed with a lower motor neuron lesion. What entry in the patients electronic record is most consistent with this diagnosis?
- A. Patient exhibits increased muscle tone.
- B. Patient demonstrates normal muscle structure with no evidence of atrophy.
- C. Patient demonstrates hyperactive deep tendon reflexes.
- D. Patient demonstrates an absence of deep tendon reflexes.
Correct Answer: D
Rationale: Lower motor neuron lesions result in flaccid paralysis, muscle atrophy, and absent deep tendon reflexes due to disrupted nerve supply to muscles. Increased tone and hyperactive reflexes indicate upper motor neuron issues.
A patient is having a fight or flight response after receiving bad news about his prognosis. What affect will this have on the patients sympathetic nervous system?
- A. Constriction of blood vessels in the heart muscle
- B. Constriction of bronchioles
- C. Increase in the secretion of sweat
- D. Constriction of pupils
Correct Answer: C
Rationale: Sympathetic activation during fight or flight increases sweat secretion, dilates heart muscle vessels, bronchodilates, and dilates pupils.
A nurse is caring for a patient diagnosed with Mnires disease. While completing a neurologic examination on the patient, the nurse assesses cranial nerve VIII. The nurse would be correct in identifying the function of this nerve as what?
- A. Movement of the tongue
- B. Visual acuity
- C. Sense of smell
- D. Hearing and equilibrium
Correct Answer: D
Rationale: Cranial nerve VIII (acoustic) governs hearing and balance, relevant in Mnires disease. Tongue movement is cranial nerve XII, visual acuity is II, and smell is I.
A patient is currently being stimulated by the parasympathetic nervous system. What effect will this nervous stimulation have on the patients bladder?
- A. The parasympathetic nervous system causes urinary retention.
- B. The parasympathetic nervous system causes bladder spasms.
- C. The parasympathetic nervous system causes urge incontinence.
- D. The parasympathetic nervous system makes the bladder contract.
Correct Answer: D
Rationale: Parasympathetic stimulation contracts the bladder, promoting urination. Retention, spasms, or incontinence are not direct parasympathetic effects.
A gerontologic nurse planning the neurologic assessment of an older adult is considering normal, agerelated changes. Of what phenomenon should the nurse be aware?
- A. Hyperactive deep tendon reflexes
- B. Reduction in cerebral blood flow
- C. Increased cerebral metabolism
- D. Hypersensitivity to painful stimuli
Correct Answer: B
Rationale: Aging reduces cerebral blood flow, impacting neurologic function. Deep tendon reflexes may decrease, cerebral metabolism declines, and pain sensitivity often diminishes in older adults.