The nurse is assessing a patient's muscle strength and movement. ...

[BrownTown3]

The nurse is assessing a patient's muscle strength and movement. What should the nurse do when completing this assessment?
 
  1. grade the posterior tibial pulses
  2. grade flaccidity
  3. observe whether strength and movement are bilaterally equal and strong
  4. ask the patient to walk normally in a heel-to-toe sequence

Question 2

To conduct the Romberg test, the nurse asks the patient to stand with the feet together and eyes closed. What must the nurse observe for the test to be considered normal?
 
  1. swaying from side to side
  2. minimal swaying for up to 20 seconds
  3. sufficient balance to hold completely still without swaying
  4. swaying to one side and loss of balance

[AmberC1996]

Answer to Question 1

Correct Answer: 3
The nurse should compare one side to the other and note any difference in strength or movement from side to side. Pulses relate to blood supply, not muscles. It is not possible to grade flaccidity. When muscles are flaccid, there is no movement. Asking the patient to walk normally in a heel-to-toe sequence assesses gait, not muscle strength and movement.

Answer to Question 2

Correct Answer: 2
A normal result of the Romberg test would be the patient displaying minimal swaying for up to 20 seconds. Some minor swaying may occur but should not cause loss of balance. The nurse should stand close to the patient to prevent falling. A positive Romberg test, in which the patient sways and may lose balance, is a sign of cerebellar dysfunction as in cerebellar ataxia.

[BrownTown3]

TYSM

[olderstudent]

Gracias!