A client who suffered a stroke 6 months ago and participating in a rehab program is able to actively move the both lower legs against gravity and some resistance. How should the nurse document this finding using the muscle strength grading scale?

Answer and Explanation

The Correct Answer is C

A) 2: A muscle strength grade of 2 indicates that the muscle can move when gravity is eliminated, such as when the limb is supported. However, it does not have enough strength to move against gravity. This grade is not appropriate for the client described, as they can move both lower legs against gravity.
B) 3: A muscle strength grade of 3 means that the muscle can move the joint against gravity but without any additional resistance. This is less than the client’s described ability, as they can move their legs against some resistance.
C) 4: A muscle strength grade of 4 indicates that the muscle can move against gravity and moderate resistance. This matches the client’s ability to actively move both lower legs against gravity and some resistance, making it the correct documentation of their muscle strength.
D) 5: A muscle strength grade of 5 indicates normal muscle strength, where the muscle can move against gravity and full resistance without any signs of fatigue. Since the client is described as moving against some resistance but not full resistance, a grade of 5 would overestimate their current muscle strength.

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Correct Answer is B

Explanation

A) Dysuria: Dysuria, or painful urination, is not typically associated with menopause. It is more commonly linked to urinary tract infections or other urinary tract conditions.
B) Dyspareunia: Dyspareunia, or pain during intercourse, is a common symptom experienced during menopause. Decreased estrogen levels can lead to vaginal dryness and thinning of vaginal tissues, contributing to discomfort during sexual activity.
C) Urinary frequency: While urinary frequency can be a symptom of various conditions, it is not a primary symptom of menopause. However, changes in estrogen levels can sometimes impact urinary function, but it is less common than symptoms like dyspareunia.
D) Vaginal discharge: Vaginal discharge is usually not a symptom of menopause. Instead, menopause is often associated with reduced vaginal discharge or dryness due to decreased estrogen levels. Increased discharge could indicate other issues such as infections or hormonal imbalances.

A. Light palpation of the abdominal right lower quadrant B. Auscultate sounds in the abdominal left lower quadrant C. Deep palpation of the abdominal left upper quadrant D. First percussion of the costovertebral angles

Correct Answer is D

Explanation

A) Light palpation of the abdominal right lower quadrant: While light palpation is generally the first step in an abdominal examination to assess for tenderness or abnormalities, the presence of pain with deep palpation of the right kidney indicates a more specific concern. This may warrant further investigation related to the kidney rather than focusing on the lower quadrant.
B) Auscultate sounds in the abdominal left lower quadrant: Auscultation is typically done before palpation to assess bowel sounds and other abnormalities. However, given the specific complaint of pain in the right kidney area, the priority should be addressing the suspected kidney issue rather than auscultating another quadrant.
C) Deep palpation of the abdominal left upper quadrant: Deep palpation in another quadrant is not immediately relevant to the complaint of pain in the right kidney. Instead, it’s crucial to focus on assessing the area directly related to the client's symptoms.
D) First percussion of the costovertebral angles: Percussion of the costovertebral angles (CVA) is a specific technique used to assess kidney tenderness and is appropriate for evaluating the potential causes of the pain in the right kidney. This examination can help determine if the pain is due to conditions like kidney infection or inflammation. Therefore, it is the most relevant next step in this situation.

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A client who suffered a stroke 6 months ago and participating in a rehab program is able to actively move the both lower legs against gravity and some resistance. How should the nurse document this finding using the muscle strength grading scale?

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Naxlex Comprehensive Predictor Exams

While at a woman's health clinic a healthy 56-year-old female client tells the nurse that she thinks she is starting the menopausal phase of her life. The nurse should instruct the client that she may experience

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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