Page 407 - Saunders Comprehensive Review For NCLEX-RN

Box 12-12

Scoring Deep Tendon Reflex Activity

0 = No response
1 + = Sluggish or diminished
2 + = Active or expected response
3 + = Slightly hyperactive, more brisk than normal; not necessarily pathological
4 + = Brisk, hyperactive with intermittent clonus associated with disease

Data from Wilson AF, Giddens JF: Health assessment for nursing practice, ed 5, St.
Louis, 2013, Mosby.

Practice Questions

90. A Spanish-speaking client arrives at the triage desk in the emergency
department and states to the nurse that an interpreter is needed. Which is the
best action for the nurse to take?
1. Have one of the client’s family members interpret.
2. Have the Spanish-speaking triage receptionist interpret.
3. Page an interpreter from the hospital’s interpreter services.
4. Obtain a Spanish-English dictionary and attempt to triage the
client.
91. The nurse is performing a neurological assessment on a client and notes a
positive Romberg’s test. The nurse makes this determination based on which
observation?
1. An involuntary rhythmic, rapid, twitching of the eyeballs
2. A dorsiflexion of the great toe with fanning of the other toes
3. A significant sway when the client stands erect with feet together,
arms at the side, and the eyes closed
4. A lack of normal sense of position when the client is unable to
return extended fingers to a point of reference
92. The nurse notes documentation that a client is exhibiting Cheyne-Stokes
respirations. On assessment of the client, the nurse should expect to note
which finding?

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