Author Question: The nurse applies resistance to the top of the client's foot and asks him to pull his toes toward ... (Read 89 times)

Redwolflake15 · **on:** Jul 23, 2018

The nurse applies resistance to the top of the client's foot and asks him to pull his toes toward his knee. The nurse observes active motion against some, but not against full, resistance. How should the nurse document this finding?

a. 5: Normal
b. 4: Slight weakness
c. 3: Weakness
d. 2: Poor ROM

Question 2

Based on developmental stage, how should the nurse modify the comprehensive physical examination of an older adult?

a. Work rapidly to finish as quickly as possible.
b. Sequence the examination to limit position changes.
c. Demonstrate equipment before using it.
d. Omit portions of the examination that may be tiring.

AngeliqueG · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

B
The nurse should document 4: Slight weakness. The following is the muscle strength rating scale:

Rating Criteria Classification
5 Active motion against full resistance Normal
4 Active motion against some resistance Slight weakness
3 Active motion against gravity Weakness
2 Passive ROM Poor ROM
1 Slight flicker of contraction Severe weakness
0 No muscular contraction Paralysis

Answer to Question 2

B
Because older adults may tire easily and because they may have stiff muscles and arthritic joints, the nurse should arrange the sequence of the examination to limit position changes. The nurse should work efficiently; however, speed is not the goal, and the nurse should observe the patient's energy level and stop for periods of rest as needed. It is appropriate to demonstrate equipment for school-age children but is not usually necessary for older adults, who have probably experienced other physical examinations. Because this is a comprehensive examination, it is not appropriate to omit portions of it because they may be tiring. As discussed, the patient should rest and then the nurse should return to the examination.