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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. In the Mini-Cog assessment, the inability to recall the three words (which tests short-term memory) while still being able to draw a clock (which tests visuospatial skills) could suggest early cognitive impairment or dementia. Dementia often presents with deficits in memory but may retain some other cognitive functions, like drawing. The result is consistent with a possible diagnosis of dementia, especially if memory issues are noted over time.
B. A delusion is a false belief held despite evidence to the contrary. Delusions are more related to psychiatric disorders and are not primarily assessed by the Mini-Cog. The Mini-Cog does not assess for delusions but rather focuses on cognitive function.
C. Depression can affect cognitive function, sometimes resulting in difficulties with concentration, memory, and other cognitive tasks. While depression can cause cognitive symptoms, it typically presents with other signs such as changes in mood, loss of interest in activities, and changes in sleep patterns.
D. Delirium is an acute, fluctuating change in cognition and attention, often caused by an underlying medical condition, medication, or intoxication. Delirium is characterized by rapid onset and fluctuating levels of consciousness and attention, which is not consistent with the Mini-Cog results showing stable performance on the clock drawing but poor recall.

A. Stationary soft palate on phonation B. Uvula and soft palate rising bilaterally C. Asymmetrical soft palate D. Deviation of uvula when client says "ah"

Correct Answer is B

Explanation

A. The soft palate should move during phonation. If it remains stationary, it could indicate a problem with cranial nerves IX and X. These nerves control the movement of the soft palate and the muscles involved in phonation.
B. This is the normal finding. During the assessment, when the patient says "ah," the uvula and soft palate should rise symmetrically. This movement indicates that cranial nerves IX and X are functioning properly. If the uvula and soft palate rise bilaterally, it means that both sides of the soft palate are being controlled correctly by these nerves.
C. Asymmetry in the soft palate could indicate dysfunction of cranial nerves IX and X. Normally, the soft palate should rise evenly on both sides when the patient says "ah." An asymmetrical soft palate suggests that one side is not functioning correctly, which may be due to nerve damage or weakness.
D. This is not a normal finding. If the uvula deviates to one side when the patient says "ah," it indicates a problem with the function of the cranial nerves. The deviation is usually towards the side opposite to the weak or affected side. This asymmetry in uvula movement can be due to a weakness or paralysis of the muscles on one side controlled by these nerves.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

When assessing cranial nerves IX and X, which of the following would the nurse consider as a normal finding?

Correct Answer is B

Explanation

A nurse is conducting a health history with a client who has recently had a stroke. The nurse notes the client is unable to speak, although his comprehension/ understanding is intact. Which disorder of speech is the nurse observing in this client?

A client is clenching the jaw closed to avoid taking a prescribed oral medication. The nurse can use this observation to confirm the client is demonstrating motor function of which cranial nerve?

Stroke Warning signs includes? Select all that applied.

When preparing to test a client for meningeal irritation, what would the nurse do first?

The nurse is admitting a client to the unit for surgery the next morning. The nurse notes that the client speaks at an accelerated pace and jumps from topic to topic no of which progresses to sensible conversation. What would the nurse document about this client?

The nurse assesses brisk reflexes in a client. The nurse would document this finding as which of the following?

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?