The nurse is performing the physical examination of a client with a suspected neurologic disorder. In addition to assessing other parts of the body, the nurse should assess for neck rigidity.

Which method should help the nurse assess for neck rigidity correctly?

Gently pressing the bones on the neck.

Moving the head toward both sides.

Lightly tapping the lower portion of the neck to detect sensation.

Moving the head and chin toward the chest.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Pressing the bones on the neck does not adequately assess for rigidity and may cause discomfort without providing useful information about the neurologic status.

Choice B rationale

Moving the head toward both sides is a method used to assess range of motion but does not specifically assess for neck rigidity, which requires specific positioning and movement.

Choice C rationale

Lightly tapping the lower portion of the neck to detect sensation does not assess for rigidity; it may be used to test sensory function rather than muscular stiffness or tension.

Choice D rationale

Moving the head and chin toward the chest is the standard method to assess for neck rigidity, especially in cases of suspected meningitis. This movement can reveal stiffness or resistance, which are key indicators of neurologic involvement.

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Correct Answer is D

Explanation

Choice A rationale

Ligaments connect bones and stabilize joints. Age-related changes in ligaments result in decreased elasticity, leading to joint stiffness but not directly causing loss of height.

Choice B rationale

Bones undergo resorption and may lose density with age, leading to osteoporosis. While this contributes to height loss, it is not typically associated with diminished range of motion or flexibility as primary symptoms.

Choice C rationale

Muscles lose mass and strength with aging, a condition known as sarcopenia. This affects flexibility and range of motion but does not lead directly to height loss.

Choice D rationale

Joints are affected by age-related changes such as cartilage wear and synovial fluid reduction, leading to stiffness, loss of flexibility, diminished range of motion, and height loss due to spinal disc compression and vertebral changes.

A. Fast for at least 8 hours. B. Completion of the bowel cleansing regimen. C. Empty bladder. D. No allergy to penicillins.

Correct Answer is C

Explanation

Choice A rationale

Fasting for at least 8 hours is usually required for certain diagnostic tests that involve anesthesia or contrast media, but it is not necessary for a bone scan. A bone scan typically involves the injection of a radioactive tracer and does not require fasting.

Choice B rationale

Completion of a bowel cleansing regimen is necessary for certain gastrointestinal procedures such as colonoscopy, but it is not relevant for a bone scan. A bone scan focuses on detecting bone abnormalities and does not involve the digestive system.

Choice C rationale

Emptying the bladder is important before a bone scan to ensure clear imaging of the pelvic bones. A full bladder can obscure the view and interfere with the accuracy of the scan. Ensuring the bladder is empty helps in obtaining better diagnostic images.

Choice D rationale

No allergy to penicillins is crucial information for procedures involving antibiotics, especially for patients with a history of allergic reactions. However, it is not pertinent to a bone scan, which uses a radioactive tracer rather than antibiotics.

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The nurse is performing the physical examination of a client with a suspected neurologic disorder. In addition to assessing other parts of the body, the nurse should assess for neck rigidity. Which method should help the nurse assess for neck rigidity correctly?

Nursing Test Bank

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The nurse is performing the physical examination of a client with a suspected neurologic disorder. In addition to assessing other parts of the body, the nurse should assess for neck rigidity.

Which method should help the nurse assess for neck rigidity correctly?