A nurse is assessing a child who has a diagnosis of muscular dystrophy. Assessment reveals that the child's muscles have greater-than-normal tone. The nurse should document the presence of which of the following?
A) Tonus
B) Flaccidity
C) Atony
D) Spasticity
Ans: D
Feedback:
A muscle with greater-than-normal tone is described as spastic. Soft and flabby muscle tone is defined as atony. A muscle that is limp and without tone is described as being flaccid. The state of readiness known as muscle tone (tonus) is produced by the maintenance of some of the muscle fibers in a contracted state.
You might also like to view...
Which of the following variables is not a component of the Gail Model?
A. Age at menarche B. Number of breast biopsies C. Age at first live birth D. Number of live births
During a health history interview, a woman states that she thinks that she has "bumps" on her labia. She also states that she is not sure how to check herself. The correct response would be to:
a. Reassure the woman that the examination will not reveal any problems. b. Explain the process of vulvar self-examination to the woman and reassure her that she should become familiar with normal and abnormal findings during the examination. c. Reassure the woman that "bumps" can be treated. d. Reassure her that most women have "bumps" on their labia.
The nurse is teaching a new nurse about types of physical injuries that can occur at birth. Which soft tissue injuries should the nurse include in the teaching? (Select all that apply.)
a. Petechiae b. Retinal hemorrhage c. Facial paralysis d. Cephalhematoma e. Subdural hematoma f. Subconjunctival hemorrhage
While observing a student pass medications, the nursing instructor correctly recognizes that further teaching is necessary if
1. The student asks the patient to state his or her name and birth date before administration. 2. The student opens the pills and places them in a medicine cup at the medication cart before administration. 3. The student performs three safety checks to evaluate right medication, dose, and time before administration. 4. The student compares the name and patient number on the medication administration record with that on the patient's armband before administration.