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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","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.

A. Develops fatigue when assisting with morning hygiene care B. Needs assistance raising her legs to put on socks C. Performs active range-of-motion (ROM) exercises of all extremities D. Demonstrates mild dyspnea when eating breakfast

Correct Answer is C

Explanation

A. Develops fatigue when assisting with morning hygiene care

Fatigue during hygiene suggests low endurance; not ready to ambulate safely.

B. Needs assistance raising her legs to put on socks

Needing assistance for simple tasks shows weakness and poor muscle control.

C. Performs active range-of-motion (ROM) exercises of all extremities

Performing full active ROM exercises indicates good muscle strength and coordination, suggesting readiness to attempt ambulation.

D. Demonstrates mild dyspnea when eating breakfast

Dyspnea with minimal activity (eating) indicates limited cardiopulmonary reserve-not yet fit to ambulate.

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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

The nurse designs care for the immobilized patient to help combat the major dangers of immobilization, which include: Select all that apply.

Correct Answer is ["A","B","C","D"]

Explanation

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Correct Answer is C

Explanation

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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