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 B
Explanation
A. The sternoclavicular joint is where the sternum (breastbone) meets the clavicle (collarbone). It plays a role in the movement of the shoulder girdle but does not involve the jaw. Issues with this joint would typically present as shoulder or chest discomfort rather than problems with the jaw.
B. The temporomandibular joint is the joint where the mandible (lower jaw) meets the temporal bone of the skull, just in front of the ear. It is crucial for jaw movement, including opening, closing, and chewing. If a client feels that their jaws are "stuck," it is likely related to a problem with the TMJ. Common issues include TMJ disorders, which can cause pain, limited movement, or a sensation of the jaw being stuck.
C. The subtalar joint is located in the ankle, between the talus and calcaneus bones. It is involved in the movement of the foot, particularly in inversion and eversion. This joint is unrelated to jaw function, so problems here would affect the foot rather than the jaw.
D. The radioulnar joints are located in the forearm and involve the radius and ulna bones. These joints are responsible for the rotation of the forearm, such as turning the palm up or down. They do not relate to jaw movement or problems, so issues with these joints would affect the forearm or wrist rather than the jaw.
Correct Answer is B
Explanation
A. Extinction refers to the phenomenon where a person fails to recognize a stimulus on one side of the body when another stimulus is presented simultaneously on the opposite side. This is often tested in cases of neurological impairment, particularly in the context of sensory neglect or loss
B. Stereognosis is the ability to identify an object by touch and proprioception without visual input. It involves recognizing the shape, size, and texture of an object solely through tactile information. Placing a coin in the patient’s hand and asking them to identify it with their eyes closed tests their ability to use tactile information to recognize objects, making stereognosis the correct term for this assessment.
C. Proprioception is the sense of the position and movement of the body and its parts. It involves awareness of body position in space, which is crucial for coordination and balance. While important, proprioception does not specifically involve identifying objects by touch alone; it is more about the awareness of body position.
D. Two-point discrimination is the ability to distinguish between two closely spaced points of contact on the skin. It tests the sensitivity of the skin to touch and is often used to assess sensory nerve function. It does not involve identifying objects by touch but rather measuring how well one can discern between two separate points of contact.
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