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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?

A.

+10

B.

+4

C.

+5

D.

+1

Answer and Explanation

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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View Related questions

Correct Answer is B

Explanation

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.

Correct Answer is D

Explanation

A) Safety issues with an unsupervised resident in the lounge area: While there could be safety concerns related to a resident being in a common area at night, the primary outcome expected from continued insomnia would more directly relate to the individual's functioning rather than immediate safety issues.

B) Onset of cardiac dysfunction: While chronic sleep disturbances can contribute to various health problems, including cardiovascular issues, the immediate outcome of insomnia is more likely to be seen in daily functioning rather than a direct onset of cardiac dysfunction.

C) Onset of new underdiagnosed health problems: While ongoing insomnia may exacerbate existing health issues or lead to new ones over time, the most immediate and observable outcome of insomnia would relate to how it affects daily functioning rather than the development of new health problems.

D) The ability to function during the day may be hindered by these episodes: Insomnia typically leads to increased fatigue, decreased alertness, and impaired cognitive function during the day. As a result, the resident's overall ability to engage in daily activities and interact socially may be significantly hindered by their lack of restorative sleep.

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