A client who suffered a stroke 6 months ago and participating in a rehab program is able to actively move the both lower legs against gravity and some resistance. How should the nurse document this finding using the muscle strength grading scale?

Answer and Explanation

The Correct Answer is C

A) 2: A muscle strength grade of 2 indicates that the muscle can move when gravity is eliminated, such as when the limb is supported. However, it does not have enough strength to move against gravity. This grade is not appropriate for the client described, as they can move both lower legs against gravity.
B) 3: A muscle strength grade of 3 means that the muscle can move the joint against gravity but without any additional resistance. This is less than the client’s described ability, as they can move their legs against some resistance.
C) 4: A muscle strength grade of 4 indicates that the muscle can move against gravity and moderate resistance. This matches the client’s ability to actively move both lower legs against gravity and some resistance, making it the correct documentation of their muscle strength.
D) 5: A muscle strength grade of 5 indicates normal muscle strength, where the muscle can move against gravity and full resistance without any signs of fatigue. Since the client is described as moving against some resistance but not full resistance, a grade of 5 would overestimate their current muscle strength.

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Correct Answer is B

Explanation

A) Lateralization of the sound/vibration to both ears equally: The Weber test is used to assess unilateral hearing loss and would not show equal lateralization in the presence of unilateral sensorineural hearing loss. Equal lateralization would suggest normal hearing or symmetrical hearing loss, which is not the case here.
B) Lateralization of the sound/vibration to the left ear: In sensorineural hearing loss, sound is perceived to lateralize to the unaffected ear. Therefore, with right ear sensorineural hearing loss, the sound will lateralize to the left ear, indicating that the left ear has better hearing capability.
C) Bone conduction (BC) is greater than air conduction (AC): This finding is characteristic of conductive hearing loss, not sensorineural hearing loss. In sensorineural hearing loss, air conduction is typically greater than or equal to bone conduction, but the Weber test focuses on lateralization rather than BC versus AC.
D) Lateralization of the sound/vibration to the right ear: If the sound were to lateralize to the affected ear in sensorineural hearing loss, it would suggest that the affected ear is hearing better, which contradicts the nature of sensorineural hearing loss. The sound will actually lateralize to the better-hearing, unaffected ear.

A. Menorrhagia B. Dysmenorrhea C. Amenorrhea D. Metrorrhagia

Correct Answer is C

Explanation

A) Menorrhagia: This term refers to heavy or prolonged menstrual bleeding. It does not relate to the absence of menstrual flow.
B) Dysmenorrhea: This term describes painful menstruation or menstrual cramps. It is not used to indicate the absence of menstrual flow.
C) Amenorrhea: This term is used to describe the absence of menstrual flow. It can be primary (never having had a menstrual period) or secondary (the cessation of menstruation after having had periods previously).
D) Metrorrhagia: This term refers to bleeding that occurs between menstrual periods. It does not describe the absence of menstrual flow.

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A client who suffered a stroke 6 months ago and participating in a rehab program is able to actively move the both lower legs against gravity and some resistance. How should the nurse document this finding using the muscle strength grading scale?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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