Question

The nurse is assessing the deep tendon reflexes of the client with hypomagnesemia. Which method is used to elicit the biceps reflex? A. The nurse places her thumb on the muscle inset in the antecubital space and taps the thumb briskly with the reflex hammer. B. The nurse loosely suspends the client's arm in an open hand while tapping the back of the client's elbow. C. The nurse instructs the client to dangle her legs as the nurse strikes the area below the patella with the blunt side of the reflex hammer. D. The nurse instructs the client to place her arms loosely at her side as the nurse strikes the muscle insert just above the wrist.

Short answer

Answer: The appropriate method is to place the nurse's thumb on the muscle inset in the antecubital space and tap the thumb briskly with the reflex hammer.

Step-by-step solution

Understand hypomagnesemia and the biceps reflex

Hypomagnesemia is a condition defined by low levels of magnesium in the blood. It can affect muscle and nerve function, including reflexes. The biceps reflex is a deep tendon reflex that tests the function of the biceps muscle and the nerves that innervate it.

Check each option

Let's analyze each given method to determine how they correlate to the biceps reflex exam. A. The nurse places her thumb on the muscle inset in the antecubital space and taps the thumb briskly with the reflex hammer. B. The nurse loosely suspends the client's arm in an open hand while tapping the back of the client's elbow. C. The nurse instructs the client to dangle her legs as the nurse strikes the area below the patella with the blunt side of the reflex hammer. D. The nurse instructs the client to place her arms loosely at her side as the nurse strikes the muscle insert just above the wrist.

Choose the correct method

The correct method to elicit the biceps reflex is found in option A. In this method, the nurse places her thumb on the muscle inset in the antecubital space and taps the thumb briskly with the reflex hammer. This action will evaluate the function of the biceps muscle and associated nerves. The other options are incorrect because: B. This method describes a technique for testing the triceps reflex, not the biceps reflex. C. This method is used to assess the patellar reflex, which is unrelated to the biceps reflex. D. Striking the muscle insert just above the wrist is a test for the brachioradialis reflex, not the biceps reflex. So, the correct answer is option A: The nurse places her thumb on the muscle inset in the antecubital space and taps the thumb briskly with the reflex hammer.

Key concepts

Nursing Assessment

Understanding nursing assessments is essential in evaluating a patient’s health status. It involves a systematic approach to observing and evaluating a patient's condition. A nursing assessment helps in identifying issues that might need medical attention. This process is crucial for devising an effective care plan tailored to the patient's unique needs.

Nurses use various assessment techniques, including observation, physical examination, and questioning. During the assessment, nurses gather data about the patient's health history, symptoms, and lifestyle. These observations help determine the most appropriate nursing interventions needed to manage or improve the patient's health condition.

• Systematic and holistic approach
• Tailored care plans
• Essential for effective treatment

Deep Tendon Reflexes

Deep tendon reflexes (DTRs) are automatic reactions of muscles to a sudden stretch induced by tapping a tendon. They are used in clinical neurology to assess the integrity of the nervous system. DTRs include reflexes such as the knee-jerk (patellar) and the biceps jerk reflex. These reflexes are part of what is known as the reflex arc, which includes a sensory nerve, a motor nerve, and the spine.

Testing these reflexes helps clinicians evaluate the function of the peripheral nerves and the spinal cord. An abnormal reflex, whether hyperactive or sluggish, could indicate neurological issues, such as nerve damage or central nervous system involvement.

• Indicators of nervous system health
• Includes various reflex tests
• Involves peripheral nerves and spinal cord

Hypomagnesemia

Hypomagnesemia signifies a deficiency of magnesium in the bloodstream, which can lead to various symptoms affecting the neuromuscular system. Magnesium is crucial for many enzymatic reactions, muscle and nerve function, and maintaining a normal heart rhythm. Without adequate magnesium, the body may show symptoms like muscle twitching, cramps, and even convulsions.

In the context of deep tendon reflex testing, hypomagnesemia can influence the results, often causing hyperactive reflexes. This condition is diagnosed through a blood test and may require dietary adjustments or supplementation to correct magnesium levels.

• Low magnesium levels in blood
• Affects muscle and nerve function
• Can cause hyperactive reflexes

Biceps Reflex

The biceps reflex test helps evaluate the C5-C6 nerve roots, which are responsible for the movement and sensation of specific areas in the arm. The test is performed by striking the tendon of the biceps muscle with a reflex hammer, while the examiner places their thumb firmly on the tendon in the antecubital fossa.

A normal reaction includes a slight flexion at the elbow, showcasing the reflex action. This test is important for determining the functionality of the muscular and nervous systems linked to these specific vertebrae. Any noticeable abnormalities in the biceps reflex might indicate neurological issues requiring further investigation.

• Tests C5-C6 nerve roots
• Involves tendon in antecubital fossa
• Evaluates muscle and nerve functionality

Reflex Hammer Technique

The reflex hammer technique is a fundamental skill for nurses and healthcare professionals when assessing deep tendon reflexes. Using the hammer, the practitioner taps the tendon briskly, typically using a relaxed wrist motion to deliver the right amount of force.

Correct positioning of the patient's limb and the health professional's hand is critical for accurate results. Positioning ensures that the proper reflex arc is engaged. It is essential to practice the technique to achieve proficiency, as improper execution can lead to inaccurate assessments.

• Essential for assessing DTRs
• Requires precise technique
• Practiced for accuracy