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 A
Explanation
A) VII: The facial nerve (cranial nerve VII) is responsible for controlling the muscles of facial expression. By assessing facial symmetry and movement, the nurse evaluates the integrity and function of this nerve, which is crucial for activities such as smiling, frowning, and raising eyebrows.
B) V: The trigeminal nerve (cranial nerve V) is primarily responsible for sensation in the face and motor functions such as chewing. While it plays a role in facial movement, it does not specifically assess facial expressions.
C) III: The oculomotor nerve (cranial nerve III) controls eye movement and pupil constriction. It does not directly influence facial expressions, so it is not the nerve being assessed in this context.
D) VI: The abducens nerve (cranial nerve VI) is responsible for lateral eye movement. It is unrelated to facial expression or symmetry and is not the focus of this assessment.