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
Related Questions
Correct Answer is C
Explanation
A. Hormonal changes can occur, but they typically do not cause significant vasodilation or hypotension in the elderly.
B. Atrophy of the muscles causing venous insufficiency. While venous insufficiency can occur in aging, muscle atrophy is not the primary factor in this issue.
C. Peripheral blood vessels become more rigid producing a rise in systolic blood pressure. This is a common and expected finding in the elderly due to arteriosclerosis, leading to increased systolic blood pressure.
D. The inferior vena cava does not typically narrow with age, and varicosities are more likely due to vein elasticity changes, not narrowing.
Correct Answer is A
Explanation
A. The whispered voice test is used to assess the function of Cranial Nerve VIII, which is responsible for hearing and balance. The nurse's whisper tests the auditory function of this nerve.
B. The vagus nerve is involved in swallowing, voice production, and parasympathetic functions but is not assessed by whispering.
C. This nerve controls lateral eye movement, and a whispered voice test does not assess eye movement.
D. This nerve also controls eye movement, specifically the superior oblique muscle, and is not evaluated by the whispered voice test.
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