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
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.
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