A patient is able to move both upper arms as follows: active movement against gravity, and some resistance. The nurse should document the muscle strength of the upper arms as:
4/5 (4 out 5 upper extremity muscle strength)
2/5 (2 out 5 upper extremity muscle strength)
5/5 (5 out Supper extremity muscle strength)
The Correct Answer is A
A. A grade of 4/5 indicates that the patient can move the upper arms against gravity and can tolerate some resistance. This aligns with the description of the patient being able to move the arms against gravity and some resistance. A grade of 4 suggests that the strength is less than normal but still functional.
B. A grade of 2/5 means the patient can move the arms only with gravity eliminated, meaning they can move the arm when it is in a horizontal position but not against gravity. Since the patient can move the arms against gravity and some resistance, this grade is too low.
C. A grade of 5/5 indicates normal strength, where the patient can move the arm against full resistance with no difficulty. The description states that the patient can move the arms against gravity and some resistance, but not necessarily against full resistance, so 5/5 might be too high of a grade in this case.
D. A grade of 0 indicates no muscle contraction or movement at all. This grade would not apply since the patient is able to move the arms against gravity and some resistance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is A
Explanation
A. Expressive aphasia (also known as Broca’s aphasia) is a condition where the individual has difficulty producing speech or writing, despite having relatively intact comprehension and awareness of their
communication difficulties. This condition often results from damage to Broca’s area in the left frontal lobe of the brain
B. Aphonia refers to the loss of voice or the inability to produce vocal sounds. It is typically associated with a physical issue affecting the vocal cords or larynx, such as vocal cord paralysis or severe laryngitis. Aphonia does not necessarily affect comprehension or the ability to understand speech, but rather the ability to produce sound.
C. Receptive aphasia (also known as Wernicke’s aphasia) is characterized by difficulty understanding or processing language, despite fluent speech production. Individuals with receptive aphasia often speak in long sentences that lack meaning or include incorrect or nonsensical words, and they have impaired comprehension
D. Dysphonia refers to difficulty in producing speech due to issues with the voice, such as hoarseness or discomfort, often related to vocal cord problems. While it affects the quality of the voice, it does not necessarily impact the ability to understand language or produce speech in a meaningful way. Dysphonia is not the correct choice for the scenario described.
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