When assessing an ambulatory patient, the nurse observes that both arms swing freely in alternation with leg swings. Which of the following is being assessed?
Muscle strength
Gait
Alignment
Joint function
The Correct Answer is B
A) Muscle strength: While muscle strength can influence gait, it specifically refers to the ability of muscles to exert force against resistance. Assessing muscle strength involves different techniques, such as manual muscle testing, rather than observing arm and leg movements.
B) Gait: The observation that both arms swing freely in alternation with leg swings is a direct assessment of the patient's gait. A normal gait pattern includes coordinated movements of the arms and legs, indicating proper motor function and balance.
C) Alignment: This term refers to the positioning of the body and its parts in relation to one another. While alignment can impact gait, it is not specifically assessed by observing the movement of the arms and legs.
D) Joint function: Joint function assessment typically focuses on the range of motion, stability, and mobility of individual joints. Observing the swing of arms and legs provides insight into overall gait rather than specific joint function.
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Correct Answer is C
Explanation
A) +10: This score does not exist on the muscle function grading scale, which typically ranges from 0 to 5. Using +10 could confuse the assessment and misrepresent the client's strength.
B) +4: This score indicates good strength against some resistance but not full strength. It suggests that the client has nearly complete function but may still have some limitations in range or strength.
C) +5: This score signifies full muscle strength and complete range of motion in a joint without any limitations. A score of +5 is what you would expect for a client demonstrating full strength, indicating optimal muscle function.
D) +1: This score indicates trace muscle contraction with minimal movement, which is far from the full strength described in the question. It suggests severe weakness and would not apply in this case.
Correct Answer is C
Explanation
A) Listen for another minute just to be sure: While it is important to confirm findings, simply listening for another minute may not provide enough time to accurately assess bowel sounds, as they can be infrequent or absent in certain conditions.
B) Contact the physician as this is a surgical emergency: Not hearing bowel sounds for a minute is not immediately indicative of a surgical emergency. It’s essential to gather more information before escalating the situation.
C) Auscultate for another 4 minutes: This is the appropriate action, as the nurse should auscultate for a total of 5 minutes (1 minute initially and then 4 more minutes) to adequately assess bowel sounds. This duration allows for the detection of normal, hypoactive, or absent bowel sounds, which can provide critical information about the client’s gastrointestinal function.
D) Listen posteriorly for enhanced bowel sounds: While listening from different positions may sometimes help, the standard practice is to listen for an appropriate duration before changing techniques. Auscultating for a longer period is more clinically relevant in this scenario.