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 A

Explanation

A. 3- This is the lowest possible score on the GCS and reflects no eye opening, no verbal response, and no motor response to stimuli. Score of 4-6: The patient might exhibit some responses, but these responses are still severely impaired. For example, the patient might open their eyes to pain but not respond verbally or move purposefully.
B. A GCS score in the range of 13 to 15 reflects a higher level of consciousness.
C. A GCS score of 0 is not a valid score on the scale.
D. A GCS score in the range of 9 to 12 reflects moderate impairment of consciousness.

A. Not allowing the client to interact with other clients B. Checking on the client every 4 hours C. Setting clear boundaries and making sure the client abides by them D. Providing a safe environment by removing items that could cause harm

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.

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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

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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