The nurse is preparing to assess the posterior spine of a client. Which landmark should the nurse use to determine symmetry?

Posterior superior iliac spine

Iliac crests

Paravertebral muscles

Twelfth thoracic vertebrae

Answer and Explanation

The Correct Answer is B

A) Posterior superior iliac spine: While this landmark is useful for certain assessments, it is more commonly used to identify pelvic alignment rather than symmetry of the spine itself.
B) Iliac crests: The iliac crests serve as an important anatomical landmark for assessing symmetry in the posterior spine. By comparing the heights of the iliac crests on both sides, the nurse can determine any asymmetry in the pelvis and, by extension, the spine, as uneven heights may indicate spinal deformities.
C) Paravertebral muscles: While assessing the paravertebral muscles can provide information about muscle tone and potential asymmetries, they are not direct landmarks for evaluating overall spinal symmetry.
D) Twelfth thoracic vertebrae: Although identifying specific vertebrae is important for certain assessments, the twelfth thoracic vertebra is not commonly used as a primary landmark for assessing symmetry in the spine. It is more useful for locating the general area of the thoracic spine.

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Correct Answer is C

Explanation

A) Notify the healthcare provider that the client is exaggerating their pain: It is inappropriate for the nurse to assume that the client is exaggerating their pain based solely on their demeanor. Pain perception is subjective and can vary greatly among individuals, especially in conditions like sickle cell anemia.

B) Wait 30 minutes and see if the client is still requesting pain medication: Delaying pain relief can lead to unnecessary suffering. Given that the client rates their pain as a 7 out of 10, which indicates significant discomfort, it is essential to address their pain promptly rather than postponing treatment.

C) Administer the pain medication as prescribed: This is the most appropriate action. Clients with sickle cell anemia often experience severe pain crises, and effective pain management is crucial. Administering the medication as prescribed supports the client's comfort and well-being.

D) Administer half of the ordered dose of pain medication: Modifying the dosage without a provider's order is not appropriate. If the full prescribed dose is warranted based on the pain level, the nurse should administer it as indicated to ensure effective pain management.

A. Friction rubs B. Crepitus C. Bruits D. High pitched gurgling

Correct Answer is D

Explanation

A) Friction rubs: These sounds are typically heard over the liver or spleen and indicate inflammation of the peritoneal surface. They are not standard findings during routine abdominal auscultation and are more specific to certain conditions.

B) Crepitus: This term refers to a crackling or popping sound often associated with joint movement or subcutaneous air and is not related to abdominal auscultation. It is not something a nurse would expect to hear when listening to bowel sounds.

C) Bruits: These are abnormal sounds that indicate turbulent blood flow, typically assessed over blood vessels rather than the abdomen itself. While they can be detected in some abdominal conditions, they are not the primary sounds expected during routine abdominal auscultation.

D) High pitched gurgling: This is characteristic of normal bowel sounds and indicates active peristalsis. High-pitched, gurgling sounds are a common finding during abdominal auscultation, reflecting the movement of gas and fluids in the intestines. This is what the nurse would expect to hear when assessing the abdomen.

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The nurse is preparing to assess the posterior spine of a client. Which landmark should the nurse use to determine symmetry?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who has pain due to sickle cell anemia. The patient rates the pain as a 7 out of 10 (O is no pain and 10 is the worst pain possible). The client is moving around easily and smiling. She is asking for pain medication. Which action by the nurse is most appropriate?

Correct Answer is C

Explanation

When assessing the abdomen, the nurse would expect to auscultate which sounds?

Correct Answer is D

Explanation

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