The nurse assesses a client who reports chronic pain with chewing. The nurse should assess which body area to investigate the client's problem further?
glenohumeral joint
sternoclavicular joint
temporomandibular joint
acromioclavicular joint
The Correct Answer is C
A. Glenohumeral joint: The glenohumeral joint is the shoulder joint. Pain with chewing is unlikely to be related to issues with the shoulder joint, as this joint is not involved in the chewing process.
B. Sternoclavicular joint: The sternoclavicular joint is where the clavicle meets the sternum. Problems here might affect shoulder and chest movement, but they would not typically cause pain specifically related to chewing.
C. Temporomandibular joint (TMJ): The TMJ is directly involved in the movement of the jaw, which is essential for chewing. Chronic pain during chewing often indicates a problem with the TMJ, such as TMJ disorder, which can cause pain, clicking, and other issues when moving the jaw.
D. Acromioclavicular joint: The acromioclavicular joint is located at the top of the shoulder where the clavicle meets the acromion of the scapula. This joint primarily affects shoulder movement, not chewing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Range of motion: Lateral bending of the spine is a movement used to assess the range of motion (ROM) of the spine, specifically the flexibility and mobility of the thoracolumbar region. By asking the client to perform lateral bends, the nurse can evaluate the extent to which the client can bend sideways and assess any limitations or discomfort in the movement.
B) Diaphragmatic excursion: Diaphragmatic excursion refers to the movement of the diaphragm during respiration and is assessed through techniques like percussion and auscultation of the lungs. Lateral bending of the spine does not provide information about diaphragmatic movement.
C) Spinous processes: The spinous processes of the vertebrae can be palpated to assess alignment and tenderness, but lateral bending does not specifically assess the spinous processes. It focuses more on the overall mobility of the spine.
D) Spinal deformities: While lateral bending can reveal limitations in spinal movement that might suggest underlying spinal deformities, it is not a primary diagnostic tool for identifying specific deformities. Other assessments, such as inspection and palpation of the spine, X-rays, or physical
Correct Answer is D
Explanation
A) "Let's stop and take your vital signs": While taking vital signs can be important, it might not address the immediate discomfort the client is experiencing from the deep palpation. This response may not fully address the need to pause the assessment in light of the client’s discomfort.
B) "We can take a break anytime": Offering a break is considerate, but it does not directly address the immediate situation. If the client is already in significant discomfort, it's more appropriate to stop the procedure entirely if the information gathered so far is sufficient.
C) "Keep taking deep breaths; you will be okay": Encouraging deep breathing may help manage some discomfort, but it doesn’t acknowledge the client's need to stop the procedure or the fact that the assessment may have already provided sufficient information.
D) "Let's stop: I have all of the information we need": Stopping the palpation when the client is experiencing pain or discomfort and when enough information has been obtained is the most appropriate response. It shows sensitivity to the client's pain and prioritizes their comfort, while also acknowledging that the assessment may have achieved its purpose.
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