The nurse assesses a client who comes to the clinic with neck stiffness and discomfort. Which finding of the cervical spine should the nurse inquire further about lifestyle habits?
Inspection of head and neck is observed in a straight alignment without lateral curves.
Evaluation of cranial nerve XI reveals flexion is maintained against full resistance.
Observation of cervical range of motion reveals flexion and extension is 25 degrees.
Palpation of the spinous processes and surrounding muscles are non-tender.
The Correct Answer is C
A) Inspection of head and neck is observed in a straight alignment without lateral curves:
This finding describes the normal alignment of the head and neck without lateral curves, indicating proper cervical spine alignment. While it provides information about cervical alignment, it does not directly suggest lifestyle habits that could contribute to neck stiffness and discomfort.
B) Evaluation of cranial nerve XI reveals flexion is maintained against full resistance:
Assessing cranial nerve XI (accessory nerve) involves testing the strength of the trapezius and sternocleidomastoid muscles. While weakness in these muscles may indicate pathology affecting the nerve, it does not specifically relate to lifestyle habits contributing to neck stiffness and discomfort.
C) Observation of cervical range of motion reveals flexion and extension is 25 degrees:
Limited cervical range of motion, such as the restricted flexion and extension described, may suggest musculoskeletal issues or lifestyle habits contributing to neck stiffness and discomfort. Further inquiry into the client's lifestyle habits, such as occupational activities, posture, and exercise habits, would be warranted to identify potential factors contributing to limited cervical range of motion.
D) Palpation of the spinous processes and surrounding muscles are non-tender:
Non-tender palpation of the spinous processes and surrounding muscles suggests the absence of acute musculoskeletal issues or inflammation in the cervical spine region. While it rules out tenderness on palpation, it does not provide specific information about lifestyle habits that could contribute to neck stiffness and discomfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Aortic site:
The aortic site is relevant for cardiac assessment but not for auscultating breath sounds.
B) Sternum:
The sternum is a bony structure and not an optimal location to start auscultating breath sounds as it can interfere with sound transmission.
C) Lung apex:
Auscultating at the lung apex, which is located just above the clavicle, is the appropriate starting point for assessing anterior breath sounds. This ensures that the upper parts of the lungs are examined first.
D) Clavicle:
While the area near the clavicle is relevant, it is more precise to refer to the lung apex, which includes the area just above the clavicle, for starting the auscultation of breath sounds.
Correct Answer is B
Explanation
A) Hypogastric region:
The hypogastric region, also known as the suprapubic region, is located below the umbilical region and above the pubic area. Pain in the hypogastric region would be lower in the abdomen than described.
B) Epigastric region:
The epigastric region is located in the upper central part of the abdomen, just below the xiphoid process. Pain localized in the middle section of the abdomen below the xiphoid process is described as occurring in the epigastric region.
C) Umbilical region:
The umbilical region is located around the navel (belly button). Pain in this area would be centered around the umbilicus and not higher up near the xiphoid process.
D) Hypochondriac region:
The hypochondriac regions are located on either side of the epigastric region and below the ribcage. Pain in the hypochondriac region would be more lateral and not centrally located below the xiphoid process.
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