DIF:Cognitive Level: ApplicationREF: p. 496OBJ: 5 (theory)TOP: Reflex: DefinitionKEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Physiological Adaptation8.The nurse interprets the physician’s finding of a grade of 2/5on the Achilles tendon to meanwhat has occurred?a.Hyperreflexive response for the fifth and sixth cervical nervesb.Exaggerated response for the seventh and eighth cervical nervesc.Normal response for the first and second sacral nervesd.Weak response for the second through the fourth lumbar nervesANS: CA score of 2/5 is a normal grade. The Achilles tendon reflex or ankle jerk reflex evaluates thefirst and second sacral nerves.Test Bank for deWit's Medical-Surgical Nursing 4th Edition Stromberg (Test Bank PDF Files)

DIF:Cognitive Level: ComprehensionREF: p. 496OBJ: 5 (theory)TOP: Reflexes: GradingKEY: Nursing Process Step: AssessmentMSC: NCLEX: Health Promotion and Maintenance9.Which reflex indicates an abnormality in the motor control pathways from the cerebralcortex?

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DIF:Cognitive Level: KnowledgeREF: p. 501, Figure 21-11GARDESLAB.COM

OBJ: 1 (theory)TOP: Babinski ReflexKEY: Nursing Process Step: AssessmentMSC: NCLEX: Health Promotion and Maintenance10.The nurse is caring for a patient with a head injury. Over a time span of 30 minutes, the nurseobserves the following vital signs changes: temperature from 97° to 98° F; pulse from 86 to78 beats per minute; respirations from 18 to 14 breaths/min; and blood pressure from 140/86to 150/82. Which action is most important for the nurse to take?