The practical nurse (PN) is performing daily assessment of a client who is admitted for a transient ischemic attack (TIA). Which technique should the PN implement to evaluate the client's upper extremity strength?

Request the client to reach for a spoon on the breakfast tray.

Tell the client to touch themself on the nose with a forefinger 5 times.

Have the client to use both hands to grip and squeeze the PN's hands.

Ask the client to extend both arms to the side and move in small to larger circles.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Request the client to reach for a spoon on the breakfast tray: Reaching for objects evaluates coordination and fine motor skills more than gross muscle strength. While it can provide some information, it is not a standardized or reliable method to assess upper extremity strength.

B. Tell the client to touch themself on the nose with a forefinger 5 times: This maneuver, known as the finger-to-nose test, assesses coordination, proprioception, and cerebellar function. It does not provide an accurate measure of muscle strength in the upper extremities.

C. Have the client use both hands to grip and squeeze the PN's hands: Handgrip strength testing is a direct, objective method to evaluate upper extremity muscle strength. By having the client squeeze the PN’s hands, the nurse can compare bilateral strength and identify weakness that may indicate neurologic impairment following a TIA.

D. Ask the client to extend both arms to the side and move in small to larger circles: This movement tests range of motion and coordination rather than strength. It is useful for assessing motor control but does not quantify or reveal muscle weakness effectively.

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Free Nursing Study Resources

Correct Answer is A

Explanation

Rationale:

A. Tonsils are observable and covered with a white exudate: White exudate on the tonsils can indicate an acute infection, such as bacterial tonsillitis or streptococcal pharyngitis, which can rapidly progress and cause systemic complications if untreated. Immediate reporting is warranted to ensure timely medical evaluation, potential antibiotic therapy, and prevention of complications

B. Ventral surface of the tongue appears smooth and glistening: A smooth, glistening tongue may reflect nutritional deficiencies, such as vitamin B12 or iron deficiency, but it is generally a chronic finding and not immediately life-threatening. It requires assessment but not urgent intervention.

C. Dorsal surface of the tongue is rough with a white coating: A white coating on the dorsal tongue often represents benign causes, such as oral candidiasis or debris accumulation. While it may require treatment, it is typically not an acute emergency unless accompanied by severe symptoms like dysphagia or systemic infection.

D. Teeth are yellowed and crooked with debris collected in the gaps: Poor dental hygiene and discoloration indicate chronic oral health issues. These findings require preventive education and routine dental care but do not demand immediate medical action.

A. Give the client an object to hold. B. Palpate the client's muscle tone. C. Instruct the client to close their eyes. D. Apply resistance to the client's arms.

Correct Answer is B

Explanation

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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The practical nurse (PN) is performing daily assessment of a client who is admitted for a transient ischemic attack (TIA). Which technique should the PN implement to evaluate the client's upper extremity strength?

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Naxlex Comprehensive Predictor Exams

When inspecting a client's oral cavity, which finding warrants immediate action by the practical nurse (PN)?

Correct Answer is A

Explanation

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?

Correct Answer is B

Explanation

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