When assessing muscle strength, the nurse observes that a patient has complete range of motion against gravity with full resistance. What grade of muscle strength should the nurse record using a 0- to 5-point scale?
Grade 1
Grade 2
Grade 3
Grade 5
The Correct Answer is D
A. This grade indicates trace contraction but no movement. It is not appropriate in this case, as the patient has full range of motion.
B. Grade 2. This grade reflects full range of motion with gravity eliminated. The patient’s range of motion is against gravity, so this is not the correct grade.
C. Grade 3. This grade indicates full range of motion against gravity but without resistance. The patient is able to resist full force, so this is not the correct grade either.
D. Grade 5. This grade indicates normal strength with full range of motion against gravity and full resistance. This best describes the patient's strength, which is normal.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is A
Explanation
A. The ballottement test involves pressing on the knee joint to check for the presence of fluid, which can indicate joint effusion.
B. The McMurray test is used to assess for meniscal tears, not for fluid around the patella.
C. The Tinel sign is used to assess for nerve compression, not fluid accumulation.
D. The Phalen test is used to diagnose carpal tunnel syndrome, not to assess for joint effusion.
Correct Answer is A
Explanation
A. Palpation should be done after auscultation to avoid altering the bowel sounds. Palpation can cause changes in the sounds, making it difficult to assess accurately.
B. It is advisable to auscultate bowel sounds when the patient is not actively eating, so this action is appropriate.
C. This is the correct duration for assessing bowel sounds. Auscultating for 3-5 minutes is within the standard practice.
D. If the client has an NG tube, clamping it before auscultation is appropriate as it prevents additional noises or interference from the tube.
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