What should the nurse include in the assessment of muscle strength and movement?
1. Grade the posterior tibial pulses.
2. Grade flaccidity.
3. Observe to see whether strength and movement are bilaterally equal and strong.
4. Percuss the muscle for dullness.
3
Rationale 1: Pulses relate to blood supply, not muscles.
Rationale 2: It is not possible to grade flaccidity. When muscles are flaccid, there is no movement.
Rationale 3: The nurse should always compare one side to the other when an extremity is being assessed and note whether there is a difference in strength or movement from side to side.
Rationale 4: Assessment of muscle strength and movement does not include percussion.
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