Published Jun 23, 2015
Crew2Nursing
65 Posts
I have a question about this test question..... Its online (Quiz-let) so I have not downloaded/or stolen it. I know the answer now... but working as a PCT......
Can you give some more detail. It would be greatly appreciated.
In assessing a 70-year-old patient who has had a recent cerebrovascular accident, the nurse notices right-sided weakness. What might the nurse expect to find when testing his reflexes on the right side?
A) Lack of reflexes
B) Normal reflexes
C) Diminished reflexes
D) Hyperactive reflexes
Answer:
Hyperreflexia is the exaggerated reflex seen when the monosynaptic reflex arc is released from the influence of higher cortical levels. This occurs with upper motor neuron lesions (e.g., a cerebrovascular accident). The other responses are incorrect
Chisca, RN
745 Posts
The question may have fooled you because you are reading right sided weakness and thinking you should see less responsiveness on the right side. You will if the patient is initiating the nerve impulse from above but in testing reflexes you are sending an impulse from below. Since there is no inhibition, because of the CVA, the response in the muscle is greater.
sirI, MSN, APRN, NP
17 Articles; 45,819 Posts
Thread moved to Student Assistance forum for best response.
Thanks.
Lev, MSN, RN, NP
4 Articles; 2,805 Posts
In general, hyperactive reflexes = bad. You'd think oh it's working very well, but in reality it's hyperactive because it doesn't have the normal inhibitions on the reflexes.