The practical nurse (PN) is assessing the client's upper extremities muscle strength. The PN asks the client to extend the arms, but before asking the client to flex the arms, which action should the PN perform?

Give the client an object to hold.

Palpate the client's muscle tone.

Instruct the client to close their eyes.

Apply resistance to the client's arms.

Answer and Explanation

The Correct Answer is B

Rationale:

A. Give the client an object to hold: Providing an object is not necessary for assessing basic muscle strength and may interfere with accurately evaluating the client’s ability to perform isolated movements. It is more relevant in functional or fine motor assessments rather than strength testing.

B. Palpate the client's muscle tone: Before testing active movements like flexion, the nurse should assess muscle tone through palpation. This allows the PN to detect hypotonia, hypertonia, or spasticity, which can affect strength testing and provide baseline information about neuromuscular function.

C. Instruct the client to close their eyes: Closing the eyes may be useful for assessing proprioception or coordination but is not essential for evaluating basic upper extremity muscle strength. Vision does not significantly impact isolated strength assessment.

D. Apply resistance to the client's arms: Resistance testing occurs after observing the client’s active movement. Applying resistance prematurely could cause discomfort or injury if the nurse has not first assessed baseline tone and voluntary control of the muscles.

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Correct Answer is D

Explanation

Rationale:

A. Continue by stroking down the medial side of the sole of the foot: Further stroking is unnecessary if the initial test elicited a normal plantar flexion response. Additional stimulation is not required to confirm a normal response and may cause discomfort to the client.

B. Repeat the same motion with the flat portion of the reflex hammer: Using the flat portion is not indicated for testing the plantar reflex. The pointed end is the standard tool for eliciting this response, and repeating the motion is unnecessary when the initial response is normal.

C. Notify the healthcare provider of the presence of a positive Babinski reflex: A positive Babinski reflex is indicated by dorsiflexion of the big toe and fanning of the other toes, which is abnormal in adults. In this patient, the toes curl downward, indicating a normal plantar flexion response; no abnormal finding exists to report.

D. Record the normal response of plantar flexion in the record: The observed downward curling of the toes represents a normal plantar reflex in an adult. Accurate documentation of this normal neurologic finding is the appropriate next step, ensuring continuity of care and baseline assessment for future comparison.

A. Auscultation. B. Observation. C. Percussion. D. Palpation.

Correct Answer is B

Explanation

Rationale:

A. Auscultation: Auscultation is used to assess internal body sounds such as bowel sounds, heart sounds, or vascular bruits. It does not provide information about skin color or pigment changes, which are essential for identifying jaundice. Therefore, it is not an appropriate technique for this assessment.

B. Observation: Jaundice is characterized by yellow discoloration of the skin, sclera, and mucous membranes due to elevated bilirubin levels. Visual inspection is the most effective way to detect these color changes, especially in natural light. The sclera is often the earliest and most reliable site to assess for jaundice.

C. Percussion: Percussion is used to assess underlying structures by evaluating sound differences, such as detecting fluid, masses, or organ enlargement. It does not provide information about skin pigmentation or bilirubin accumulation, so it is not useful in identifying jaundice.

D. Palpation: Palpation involves using touch to assess for tenderness, masses, or organ size, such as liver enlargement. While helpful in evaluating liver pathology, it does not detect the yellow discoloration associated with jaundice, which is a visual finding.

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The practical nurse (PN) is assessing the client's upper extremities muscle strength. The PN asks the client to extend the arms, but before asking the client to flex the arms, which action should the PN perform?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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