Which score would a nurse select from the muscle function grading scale if the client has full strength and range of motion in a given joint?
+10
+4
+5
+1
The Correct Answer is C
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.
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Correct Answer is D
Explanation
A) "Have you ever had any surgeries?": While this question is important, it is more specific and may not provide the comprehensive context needed to guide the interview. It could lead to a narrow focus on past surgical history without addressing the client’s current health status or concerns.
B) "Tell me about any medical problems that you have had.": This question is useful but lacks the immediate relevance to the client's current situation. It may prompt the client to recount past issues rather than focusing on their current health needs and reasons for seeking care.
C) "Tell me about any medications you are currently taking.": This is an essential aspect of health history, but like the previous options, it doesn't address the client’s immediate concerns or symptoms that may guide the rest of the interview.
D) "Tell me why you are seeking care today.": This question is the most effective starting point as it directly addresses the client’s current health issue or concern. Understanding the reason for seeking care helps the nurse prioritize topics, gather relevant information, and tailor the rest of the health history interview to the client’s specific needs, making it a crucial guide for further questioning.
Correct Answer is A
Explanation
A) Stiff neck and shoulder pain: This symptom is very common in clients with a herniated cervical disc. The herniation can lead to irritation or compression of nearby nerves, resulting in localized pain in the neck and shoulder region. Clients often report this discomfort as one of their primary concerns.
B) Cauda equina syndrome: This serious condition arises from compression of the cauda equina, which occurs in the lower lumbar region of the spine, not the cervical area. Therefore, it is not a typical symptom of a cervical disc herniation.
C) Changes in knee and ankle reflexes: These changes are more associated with lumbar spine issues. While cervical disc problems can affect reflexes, they typically do not present as changes in lower limb reflexes, which are primarily linked to lower back conditions.
D) Sciatica: This term usually refers to pain that radiates down the leg due to compression of the sciatic nerve, often associated with lumbar disc herniation. It is not a common symptom of cervical disc herniation, which affects the neck and upper extremities.