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 B

Explanation

Choice A rationale

Dysfunction in the cerebrum would likely result in different types of posturing, such as decorticate posturing, rather than decerebrate. The cerebrum is involved in controlling voluntary motor functions and damage here typically does not lead to decerebrate posturing.

Choice B rationale

Dysfunction in the brain stem results in decerebrate posturing, characterized by rigid extension of the arms and legs, downward pointing of the toes, and backward arching of the head. The brain stem is crucial for controlling basic life functions and its impairment leads to severe motor response issues.

Choice C rationale

Dysfunction in the spinal column typically does not lead to decerebrate posturing but may lead to different types of paralysis or movement issues depending on the location and severity of the damage.

Choice D rationale

Dysfunction in the motor cortex usually leads to abnormalities in voluntary movement, muscle tone, and coordination rather than decerebrate posturing which is more linked to brain stem issues.

A. "You may experience progressive deterioration in all voluntary muscles.”. B. "The strength of your arms and pelvic muscles will decrease gradually, but this should cause only slight disability.”. C. "You should ask your health care provider about that.”. D. "This form of muscular dystrophy is a relatively benign disease that progresses slowly.”. .

Correct Answer is A

Explanation

Choice A rationale

Mixed muscular dystrophy leads to progressive deterioration in all voluntary muscles, causing increasing disability over time.

Choice B rationale

This statement is incorrect because mixed muscular dystrophy affects more than just the arms and pelvic muscles and leads to significant disability.

Choice C rationale

This is not an appropriate response as it does not provide any information and deflects the client's question.

Choice D rationale

Mixed muscular dystrophy is not considered benign, as it causes significant and progressive muscle deterioration.

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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?

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A nurse observes that decerebrate posturing is a comatose client's response to painful stimuli. Decerebrate posturing as a response to pain indicates:

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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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?