A client is able to actively move the right arm against gravity. How should the nurse document this finding using the muscle strength grading?

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. The trigeminal nerve (CN V) is primarily responsible for sensory information from the face and motor control of the muscles of mastication (chewing). It does not carry taste sensations. Instead, it is involved in sensation (e.g., touch, pain, temperature) of the face and mouth, but not taste.
B. The vagus nerve (CN X) has various functions, including parasympathetic control of the heart, lungs, and digestive tract, and sensory and motor functions in the throat and voice box. It does contribute to taste sensation in the region of the pharynx and the epiglottis, but it is not primarily responsible for the taste sensation on the posterior third of the tongue.
C. The glossopharyngeal nerve (CN IX) is responsible for taste sensation on the posterior one-third of the tongue. It also contributes to the sensory innervation of the pharynx and helps in the regulation of saliva production. This nerve is specifically involved in the taste perception in the back third of the tongue.
D. The facial nerve (CN VII) provides taste sensation to the anterior two-thirds of the tongue. It also controls the muscles of facial expression and contributes to the production of saliva and tears. The facial nerve does not provide taste sensation to the posterior third of the tongue.

A. perseveration B. flight of ideas C. derailment D. confabulation E. negative Babinski reflex

Correct Answer is D

Explanation

A. Perseveration refers to the repetition of a particular response or behavior despite the cessation of the stimulus that prompted it. This often occurs in individuals with neurological disorders, where they keep repeating the same word, phrase, or action.
B. Flight of ideas is a rapid flow of thoughts where the person moves quickly from one topic to another, often with tangential or disconnected ideas. It is commonly observed in conditions such as mania or hypomania.
C. Derailment, also known as loosening of associations, is a thought disorder where a person’s speech goes off-topic and seems disorganized. The connections between ideas are loose or fragmented, making the conversation difficult to follow.
D. Confabulation is a memory disturbance where a person creates false memories or fabricated details to fill in gaps in their memory. The individual does not intentionally deceive but genuinely believes their fabricated information is true.

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A client is able to actively move the right arm against gravity. How should the nurse document this finding using the muscle strength grading?

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Naxlex Comprehensive Predictor Exams

Taste in the 1/3 posterior of your tongue is given by:

Correct Answer is C

Explanation

While conducting an assessment the nurse suspects that a client is making up things in response to specific questions. What behavior is this client demonstrating?

Correct Answer is D

Explanation

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Which of the following tests would be most appropriate for the nurse to use when assessing motor function of the trigeminal nerve?

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