Practice Question
A client is able to actively move the right arm against gravity. How should the nurse document this finding using the muscle strength grading?
Answer Choices:
Correct Answer:
3
Rationale:
⚫ A strength grade of 3 indicates movement against gravity but not against resistance.
⚫ Used to document muscle performance in neurological exams.
⚫ Helps in tracking recovery from stroke, injury, or surgery.
⚫ Objective scale allows for inter-provider communication.
⚫ Essential in evaluating need for rehabilitation or therapy.
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This question is from RN ATI~Health Assessment which contains 34 questions.
More Questions from This Exam
When assessing cranial nerves IX and X, which of the following would the nurse consider as a normal finding?
Answer Choices:
A. Stationary soft palate on phonation
B. Uvula and soft palate rising bilaterally
C. Asymmetrical soft palate
D. Deviation of uvula when client says "ah"
A nurse is conducting a health history with a client who has recently had a stroke. The nurse notes the client is unable to speak, although his comprehension/ understanding is intact. Which disorder of speech is the nurse observing in this client?
Answer Choices:
A. Expressive Aphasia
B. Aphonia
C. Receptive Aphasia
D. Dysphonia
A nurse is performing a physical examination on a patient. When the patient is asked to protrude his tongue, the nurse noticed a deviation from the midline to the right side. This is related to a lesion of:
Answer Choices:
A. CN V
B. CN XII
C. CN VII
D. CN I
Which of the following would the nurse most likely expect to find when assessing a client diagnosed with a frontal lobe contusion (in the Broca's Area) following a motor vehicle accident?
Answer Choices:
A. Blurred vision
B. Difficulty speaking
C. Loss of tactile sensation
D. inability to hear high-pitched sounds
A patient is able to move both upper arms as follows: active movement against gravity, and some resistance. The nurse should document the muscle strength of the upper arms as:
Answer Choices:
A. /5 (4 out 5 upper extremity muscle strength)
B. 2/5 (2 out 5 upper extremity muscle strength)
C. 5/5 (5 out Supper extremity muscle strength)
D. 2/5(5 out supper extremity muscle strength)
Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI Adult Health
- Answer Choices: 4