A nurse is assisting a client with range-of-motion exercises of the neck. Which of the following terms should the nurse use when documenting the client touching her chin to her chest?
Hyperextension
Lateral flexion
Rotation
Flexion
The Correct Answer is D
A. Hyperextension
Hyperextension refers to bending backward beyond the normal range.
B. Lateral flexion
Lateral flexion involves bending the neck to the side, ear toward shoulder.
C. Rotation
Rotation refers to turning the head side-to-side (e.g., shaking head “no”).
D. Flexion
Touching the chin to the chest is flexion of the neck-bending forward.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","E"]
Explanation
A. Using the spreader bar to turn the patient.
The spreader bar is not designed for lifting or turning; it maintains cast shape and stability.
B. Protecting the cast from soiling.
Soiling the cast can lead to skin irritation and infection, especially in the perineal area.
C. Grasping the cast over the leg to help in turning.
This can cause pressure points or cast damage; turning should be done using proper support techniques.
D. Easing itching under the cast by scratching with a bent coat hanger.
This is unsafe and can cause skin injury or infection under the cast.
E. Turning frequently to the prone position.
Frequent position changes, including prone if tolerated, help prevent pressure sores and promote circulation.
Correct Answer is B
Explanation
A. Reassess the area in 8 hours
Delaying action may result in wound dehiscence or further tissue damage.
B. Stop the machine and notify the primary care provider
Signs of wound stress (opening, tightness) require immediate discontinuation of the CPM and notification of the provider to prevent further damage.
C. Increase the angle of the flexion of the joint to change the pressure on the heel
Increasing the angle may worsen the wound separation and increase pressure on the incision.
D. Pad the portion of the machine that the heel rests on
Padding may prevent pressure injury but does not address the wound issue or tightness from movement.
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