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 D

Explanation

A) Carotid bruits: Carotid bruits are associated with turbulent blood flow in the carotid arteries, often due to stenosis or atherosclerosis. While they are important to assess in cardiovascular evaluations, they are not specific indicators of congestive heart failure (CHF).
B) 4th heart sound (S4): An S4 heart sound is associated with decreased ventricular compliance and is often seen in conditions like hypertension and left ventricular hypertrophy. It is not specific to CHF but can be present in patients with heart failure.
C) Harsh holosystolic murmur at the apex: A harsh holosystolic murmur is characteristic of mitral regurgitation, which can contribute to heart failure. However, this type of murmur is not specifically used to diagnose CHF but rather to identify the underlying cardiac pathology that could lead to CHF.
D) 3rd heart sound (S3): The S3 heart sound, often described as a "gallop," is commonly associated with congestive heart failure. It occurs due to increased fluid volume and rapid ventricular filling, reflecting the heart's struggle to manage increased blood volume and pressure, making it a key sign of CHF.

A. this is an abnormal breath sound due to bronchial airways being narrowed, bronchoconstriction B. this is a normal breath sound due to normal gas exchanged C. this is an abnormal breath sound due to bronchial airways being dilated, bronchodilation D. this is a normal breath sound due to the alveoli being fluid-filled

Correct Answer is A

Explanation

A) This is an abnormal breath sound due to bronchial airways being narrowed, bronchoconstriction: Wheezing is an abnormal breath sound characterized by a high-pitched whistling noise produced during breathing. It occurs when the bronchial airways are narrowed due to bronchoconstriction, inflammation, or mucus, common in conditions like asthma. This narrowing of the airways creates turbulent airflow, leading to the wheezing sound.

B) This is a normal breath sound due to normal gas exchange: Wheezing is not a normal breath sound and is indicative of an obstruction or narrowing in the airways. Normal breath sounds, such as vesicular breath sounds, are smooth and do not include wheezing.

C) This is an abnormal breath sound due to bronchial airways being dilated, bronchodilation: Wheezing results from airway narrowing, not dilation. Bronchodilation, which is the widening of the airways, would typically reduce or resolve wheezing rather than cause it.

D) This is a normal breath sound due to the alveoli being fluid-filled: Wheezing is related to airway narrowing rather than fluid in the alveoli. Fluid in the alveoli would more commonly cause crackles or rales, not wheezing.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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