In which way should a nurse assess muscle tone?

Muscle tone represents the tonic contraction of fibers that maintains posture and resists stretch. It is evaluated by moving a limb through its passive range of motion while assessing for hypotonia, spasticity, or rigidity. This physical finding helps localize lesions to either the corticospinal or extrapyramidal pathways. A. Use a goniometer: A goniometer is an instrument used to measure the specific degree of joint range of motion, such as how many degrees a knee can flex. It quantifies joint mobility rather than the quality of muscle resistance or tone. It is a tool for measuring distance, not tension. B. Feel the resistance to passive stretch: By moving the patient's relaxed limb, the nurse can feel the natural "give" or resistance of the muscles. This is the standard clinical method for assessing tone. It allows for the identification of abnormal resistance like spasticity or lead-pipe rigidity. C. Determine muscle temperature: Skin or muscle temperature is assessed to check for inflammation, infection, or vascular perfusion. While a warm muscle may indicate an underlying inflammatory process, temperature does not correlate with neurological muscle tone. It is an integumentary or vascular finding. D. Squeeze the muscle: Palpating or squeezing a muscle belly can identify tenderness, masses, or atrophy, but it does not evaluate how the muscle responds to movement. Tone is a dynamic property of the nervous system. Squeezing assesses tissue consistency rather than neurological tension.