A client is able to actively move the right arm against gravity. How should the nurse document this finding using the muscle strength grading?

Answer and Explanation

The Correct Answer is A

A.   muscle strength grade of 3 indicates that the client can move the arm (or other limb) against gravity but not against any additional resistance. In this case, if the client is able to actively move the right arm against gravity, this is a correct grading. The ability to move the arm against gravity alone aligns with a grade of 3.
B.   A muscle strength grade of 2 indicates that the client can move the arm (or other limb) only with gravity eliminated. This means that the client can move the limb when it is placed in a horizontal position but not against gravity. Since the client can move the arm against gravity, this grade is not applicable.
C.   A muscle strength grade of 1 indicates that there is muscle contraction but no movement of the limb. This means there is some visible muscle activity but insufficient to cause any joint movement. Since the client is able to move the arm actively against gravity, this grade does not fit the observed finding.

D.   A muscle strength grade of 5 indicates normal strength, where the client can move the limb against gravity and against full resistance. If the client can move the right arm against gravity but not necessarily against full resistance, this is not indicative of a grade of 5. The grade of 5 would be reserved for when the muscle can move against full resistance without difficulty.

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Correct Answer is B

Explanation

A. The sternoclavicular joint is where the sternum (breastbone) meets the clavicle (collarbone). It plays a role in the movement of the shoulder girdle but does not involve the jaw. Issues with this joint would typically present as shoulder or chest discomfort rather than problems with the jaw.
B. The temporomandibular joint is the joint where the mandible (lower jaw) meets the temporal bone of the skull, just in front of the ear. It is crucial for jaw movement, including opening, closing, and chewing. If a client feels that their jaws are "stuck," it is likely related to a problem with the TMJ. Common issues include TMJ disorders, which can cause pain, limited movement, or a sensation of the jaw being stuck.
C. The subtalar joint is located in the ankle, between the talus and calcaneus bones. It is involved in the movement of the foot, particularly in inversion and eversion. This joint is unrelated to jaw function, so problems here would affect the foot rather than the jaw.
D. The radioulnar joints are located in the forearm and involve the radius and ulna bones. These joints are responsible for the rotation of the forearm, such as turning the palm up or down. They do not relate to jaw movement or problems, so issues with these joints would affect the forearm or wrist rather than the jaw.

A. The patient demonstrates Flight of ideas B. demonstrates confabulation C. depressed D. demonstrates schizophrenia

Correct Answer is A

Explanation

A. Flight of ideas is characterized by a rapid and continuous flow of thoughts where the individual frequently shifts topics, often making it difficult to follow their conversation. This is commonly observed in conditions like mania or hypomania, often seen in bipolar disorder.
B. Confabulation involves fabricating or inventing stories or information to fill in gaps in memory. It is often seen in conditions affecting memory or cognition, such as Korsakoff’s syndrome or certain types of dementia.
C. Depression typically involves symptoms such as low mood, decreased energy, and lack of interest in activities, rather than rapid speech or topic shifts. The client’s accelerated pace of speech and jumping from topic to topic do not align with the characteristics of depression.
D. Schizophrenia is a broad term for a range of symptoms, including hallucinations, delusions, disorganized thinking, and impaired social functioning. While disorganized thinking can be a symptom of schizophrenia, the specific behavior described (accelerated speech and jumping topics) more specifically indicates flight of ideas, which is not exclusive to schizophrenia.

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A client is able to actively move the right arm against gravity. How should the nurse document this finding using the muscle strength grading?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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