Author Question: The nurse is assessing muscle strength in a fully conscious patient as part of a neurologic ... (Read 229 times)

abern · **on:** Jun 25, 2018

The nurse is assessing muscle strength in a fully conscious patient as part of a neurologic assessment. Which technique should the nurse employ?

a. Press down on the patient's extended arms one at a time while the patient attempts to raise the arm.
b. Apply pressure above the eye and push upward while the patient attempts to re-move the hand.
c. Pinch the trapezius muscle at the angle of the shoulder and neck while twisting the fingers slightly.
d. Rub the sternum with fisted knuckles in a twisting motion while the patient attempts to remove the fist.

Question 2

The patient is caring for a patient who spontaneously opens his eyes, localizes pain, and carries out confused conversation. The nurse correctly documents which Glasgow Coma Scale (GCS) rating for this patient?

a. 12
b. 13
c. 14
d. 15

Ksh22 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

A
To test muscle strength, have the patient extend her arms in front of her, and press down on each arm one at a time, while asking her to try to raise her arm. Applying pressure above the eye, pinching the trapezius muscle, or employing a sternal rub tests the degree of unconsciousness in a patient (and does not include asking the patient to attempt to remove the hand).

Answer to Question 2

B
The GCS is used to evaluate a patient's neurologic functioning and level of consciousness. Scores range from 3 to 15 points. The higher the score, the higher the level of consciousness. Spontaneous eye movement (4 points), localizing pain (5 points), and confused conversation (4 points) total a GCS rating of 13.