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
Explanation
A. "Keep your head straight and turn it as far as possible to either side."
This is rotation, not hyperextension.
B. "Move your head from the upright position back as far as you can."
This describes hyperextension, which is the movement of the head beyond the neutral upright position.
C. "Move your head so that your chin rests on your chest."
This is flexion, not hyperextension.
D. "Move your head laterally towards your right and left shoulder."
This describes lateral flexion, not hyperextension.
Correct Answer is ["A","B","C","D"]
Explanation
A. Loss of calcium from bone matrix
Immobility causes bone demineralization, increasing the risk for osteoporosis and fractures.
B. Stasis of respiratory secretions
Lack of movement decreases chest expansion, leading to retained secretions and risk of pneumonia or atelectasis.
C. Increased cardiac workload
Immobilization leads to venous stasis and reduced venous return, increasing cardiac workload and risk of thromboembolism.
D. Decreased circulation from pressure
Prolonged pressure leads to reduced perfusion, increasing risk for pressure ulcers.
E. Increased mental activity
Immobilization often results in decreased mental stimulation, potentially leading to depression or confusion, especially in older adults.
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