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A nurse is collecting data about a client's range of motion. Which of the following instructions should the nurse give to the client to observe hyperextension of the neck?

"Keep your head straight and turn it as far as possible to either side."

"Move your head from the upright position back as far as you can."

"Move your head so that your chin rests on your chest."

"Move your head laterally towards your right and left shoulder."

Answer and Explanation

The Correct Answer is B

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.

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Correct Answer is A

Explanation

A. Extend one leg and allow the client to slide down the leg to the floor.

It helps to control the fall, protects the client from injury, and allows the nurse to safely guide the client to the floor without using excessive force.

B. Move both feet together when the client begins to fall.

Keeping the feet together reduces stability and increases the risk of both the client and nurse falling.

C. Wrap both arms around the client's arm and shoulders.

This could cause injury to the client’s upper body and doesn't provide support for a safe fall.

D. Protect the client's extremities while lowering them to the floor.

While protecting extremities is important, the nurse’s primary action should be to use proper body mechanics (like extending one leg) to safely lower the client.

A. Move overbed tables away from the bed. B. Instruct the clients to use the call light. C. Perform client checks every 4 hr. D. Keep the clients' rooms dark. E. Place a fall risk wristband on each of the clients.

Correct Answer is ["B","E"]

Explanation

A. Move overbed tables away from the bed

Overbed tables should be kept within reach so clients don’t overextend or stand unsafely to access them.

B. Instruct the clients to use the call light

Reinforcing use of the call light promotes help-seeking before unsafe mobility attempts.

C. Perform client checks every 4 hr

High-risk clients should be checked more frequently, typically every hour or two, especially overnight.

D. Keep the clients' rooms dark

Poor lighting increases fall risk. A night light should be used.

E. Place a fall risk wristband on each of the clients

Fall risk wristbands alert staff and ensure precautions are taken consistently.

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A nurse is collecting data about a client's range of motion. Which of the following instructions should the nurse give to the client to observe hyperextension of the neck?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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Correct Answer is ["B","E"]

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