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 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.
Correct Answer is B
Explanation
A) To determine the location of the pain: While knowing the location of the pain can be relevant for overall assessment, this is not the main reason for reassessing pain after treatment. The focus is more on understanding the response to treatment rather than just identifying where the pain is.
B) To establish the effectiveness of medication: Reassessing pain after treatment is essential to evaluate how well the medication has alleviated the pain. This helps the nurse determine if the current pain management approach is effective or if modifications are necessary to improve the patient's comfort.
C) To make changes to the patient's pain goal: While understanding pain levels can inform care planning, the primary purpose of reassessing pain is to gauge treatment effectiveness rather than directly changing the pain management goals at that moment.
D) To measure the pain's duration: Measuring the duration of pain may be useful in a broader context of pain management, but it is not the immediate rationale for reassessing pain after treatment. The focus should be on the effectiveness of the intervention rather than just how long the pain lasts.