A client is able to actively move the right arm against gravity. How should the nurse document this finding using the muscle strength grading?
3
2
1
5
The Correct Answer is A
A. muscle strength grade of 3 indicates that the client can move the arm (or other limb) against gravity but not against any additional resistance. In this case, if the client is able to actively move the right arm against gravity, this is a correct grading. The ability to move the arm against gravity alone aligns with a grade of 3.
B. A muscle strength grade of 2 indicates that the client can move the arm (or other limb) only with gravity eliminated. This means that the client can move the limb when it is placed in a horizontal position but not against gravity. Since the client can move the arm against gravity, this grade is not applicable.
C. A muscle strength grade of 1 indicates that there is muscle contraction but no movement of the limb. This means there is some visible muscle activity but insufficient to cause any joint movement. Since the client is able to move the arm actively against gravity, this grade does not fit the observed finding.
D. A muscle strength grade of 5 indicates normal strength, where the client can move the limb against gravity and against full resistance. If the client can move the right arm against gravity but not necessarily against full resistance, this is not indicative of a grade of 5. The grade of 5 would be reserved for when the muscle can move against full resistance without difficulty.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Extinction refers to the phenomenon where a person fails to recognize a stimulus on one side of the body when another stimulus is presented simultaneously on the opposite side. This is often tested in cases of neurological impairment, particularly in the context of sensory neglect or loss
B. Stereognosis is the ability to identify an object by touch and proprioception without visual input. It involves recognizing the shape, size, and texture of an object solely through tactile information. Placing a coin in the patient’s hand and asking them to identify it with their eyes closed tests their ability to use tactile information to recognize objects, making stereognosis the correct term for this assessment.
C. Proprioception is the sense of the position and movement of the body and its parts. It involves awareness of body position in space, which is crucial for coordination and balance. While important, proprioception does not specifically involve identifying objects by touch alone; it is more about the awareness of body position.
D. Two-point discrimination is the ability to distinguish between two closely spaced points of contact on the skin. It tests the sensitivity of the skin to touch and is often used to assess sensory nerve function. It does not involve identifying objects by touch but rather measuring how well one can discern between two separate points of contact.
Correct Answer is B
Explanation
A. The sternoclavicular joint is where the sternum (breastbone) meets the clavicle (collarbone). It plays a role in the movement of the shoulder girdle but does not involve the jaw. Issues with this joint would typically present as shoulder or chest discomfort rather than problems with the jaw.
B. The temporomandibular joint is the joint where the mandible (lower jaw) meets the temporal bone of the skull, just in front of the ear. It is crucial for jaw movement, including opening, closing, and chewing. If a client feels that their jaws are "stuck," it is likely related to a problem with the TMJ. Common issues include TMJ disorders, which can cause pain, limited movement, or a sensation of the jaw being stuck.
C. The subtalar joint is located in the ankle, between the talus and calcaneus bones. It is involved in the movement of the foot, particularly in inversion and eversion. This joint is unrelated to jaw function, so problems here would affect the foot rather than the jaw.
D. The radioulnar joints are located in the forearm and involve the radius and ulna bones. These joints are responsible for the rotation of the forearm, such as turning the palm up or down. They do not relate to jaw movement or problems, so issues with these joints would affect the forearm or wrist rather than the jaw.
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