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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is C
Explanation
A) Short stature: While body height can play a role in overall musculoskeletal health, short stature is not specifically identified as a risk factor for disc herniation. Other physical characteristics have a more direct impact on spinal issues.
B) Anorexia: Although nutritional status is important for general health, anorexia is not a recognized risk factor for disc herniation. The condition is more related to physical stressors and age rather than dietary habits alone.
C) 39 years of age: Age is a significant risk factor for disc herniation. Most cases occur in adults aged 30 to 50, as degenerative changes in the spine increase vulnerability to herniation. At 39, the client falls within this high-risk age range.
D) Female gender: While certain musculoskeletal conditions may vary by gender, disc herniation does not have a strong gender predisposition. Both men and women are equally affected, making this option less relevant as a specific risk factor.
Correct Answer is A
Explanation
A) Symmetry: During a breast inspection, the nurse should assess for symmetry between the two breasts. It is normal for there to be some slight differences, but significant asymmetry can indicate underlying issues that may need further evaluation.
B) Hard nodules: While the presence of hard nodules would be a significant finding, this would typically be assessed through palpation rather than inspection. The initial visual assessment focuses on appearance, shape, and symmetry.
C) Skin texture: Skin texture may be observed during inspection, but it is not a primary finding that stands out as a key assessment element. It can be noted as part of a comprehensive evaluation but is not the main focus.
D) Tenderness: Tenderness is a subjective assessment that is evaluated through palpation and client reporting, rather than through inspection. The nurse cannot document tenderness solely based on visual assessment.