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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. To assess the maxillary sinuses, the nurse should apply gentle pressure to the area above and below the cheekbones, as this is where the maxillary sinuses are located.
B. The tragus is part of the ear and not relevant to the assessment of the maxillary sinuses. Pressure in this area would not be helpful for evaluating sinus health.
C. While a history of headaches may be relevant to sinus issues, it is not a direct physical assessment of the maxillary sinuses.
D. Ask if the client has a history of sinus infections. While a history of sinus infections is useful, it does not replace the physical assessment of the maxillary sinuses.

A. Cerebral palsy. B. Cerebellar ataxia. C. Muscular dystrophy D. Parkinsonism.

Correct Answer is D

Explanation

A. Cerebral palsy affects movement and coordination but typically presents with different types of motor impairment and not the specific signs of Parkinsonism.
B. Ataxia involves a lack of coordination, often affecting gait, but it would not typically involve the specific signs such as pill-rolling tremor or stooped posture.
C. Muscular dystrophy involves muscle weakness and atrophy but does not typically cause the motor symptoms observed in this patient.
D. Parkinson's disease is characterized by the classic signs of tremor (pill-rolling), bradykinesia (slow movement), postural instability, and a shuffling gait, which the patient exhibits.

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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?

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Naxlex Comprehensive Predictor Exams

When performing a physical assessment of a client's maxillary the nurse should.

Correct Answer is A

Explanation

During an assessment of a 62-year-old man, the nurse notices the patient has a stooped posture, shuffling walk with short steps, flat facial expression, and pill-rolling finger movements. These findings would be consistent with:

Correct Answer is D

Explanation

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