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)

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. While isolation may be necessary in certain situations to ensure safety, it is not the most critical
intervention. It’s essential to balance safety with providing the client with support and not making them feel isolated or abandoned. The primary focus should be on creating a safe environment and addressing the immediate risk of self-harm.
B. Checking on the client every 4 hours may not be frequent enough for a client who is at risk of self- harm or suicide. More frequent monitoring is typically required, especially if the client is deemed at high risk. Immediate and continuous observation is often necessary to prevent further attempts.
C. While setting boundaries is important for therapeutic interactions, it is secondary to addressing immediate safety concerns. The primary focus should be on preventing self-harm and ensuring a safe environment rather than just enforcing rules.
D. Providing a safe environment by removing items that could cause harm is the most crucial intervention for a client who has attempted suicide. This step directly addresses the risk of self-harm and helps prevent further suicide attempts. Creating a safe environment is a fundamental aspect of suicide prevention and immediate care.

A. Lock the fingers together and pull against each other. B. Squeeze a thigh with the opposite hand. C. Stretch the arms over the head. D. Clench the jaw tightly

Correct Answer is A

Explanation

A. This maneuver is intended to engage other muscle groups and increase overall muscle tone. It can help facilitate the patellar reflex by increasing muscle tension and sensitivity. This technique can enhance the reflex response by engaging the client in a physical action that might make the reflex more pronounced.
B. Squeezing the thigh might create discomfort or involuntary muscle contraction, which could interfere with the reflex response. It is not a recommended technique for eliciting the patellar reflex and may not have a significant effect on reflex assessment.
C. Stretching the arms over the head does not directly influence the patellar reflex. Reflexes are typically assessed in a relaxed state, and this action might not be relevant for improving the patellar reflex response.
D. Clenching the jaw might increase overall muscle tone temporarily, but it does not directly impact the patellar reflex. This technique is less likely to influence the patellar reflex compared to techniques that engage lower body muscle groups.

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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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When implementing nursing interventions for a client who has attempted suicide, which of the following is most important?

Correct Answer is D

Explanation

A nurse is having difficulty eliciting a patellar reflex. Which of the following would be most appropriate for the nurse to have the client do?

Correct Answer is A

Explanation

After a physical assessment, the nurse determines that a client has full range of motion of the temporomandibular joint. Which of the following assessments did the nurse complete with the client? Select all that apply.

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