Which instructions should the nurse provide a client to assess the lateral flexion?

"Attempt to rotate your head in a circular manner.""

"Lean your head to the side and attempt to touch your ear to your shoulder."

"Attempt to raise your shoulders up toward your ears."

"Tilt your head back and look at the ceiling."

Answer and Explanation

The Correct Answer is B

A) "Attempt to rotate your head in a circular manner": This instruction is focused on rotation rather than lateral flexion. While rotation assesses different neck movements, it does not specifically evaluate lateral flexion.

B) "Lean your head to the side and attempt to touch your ear to your shoulder": This instruction directly assesses lateral flexion of the neck. It encourages the client to bend their head to the side, effectively demonstrating the range of motion in that direction.
C) "Attempt to raise your shoulders up toward your ears": This instruction assesses shoulder elevation and shrugging rather than lateral flexion of the neck. It does not provide information about the lateral movement of the head.

D) "Tilt your head back and look at the ceiling": This instruction assesses extension of the neck rather than lateral flexion. It evaluates the ability to move the head backward.

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Correct Answer is B

Explanation

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.

A. The patient's integumentary system is within normal limits for his age B. The patient may have a metabolic condition causing him to feel cold C. The patient has abnormal thinning of skin D. The patient should have elastic turgor

Correct Answer is B

Explanation

A) The patient's integumentary system is within normal limits for his age: While thinning skin and decreased turgor can be common in older adults, the specific combination of findings, including the patient feeling cold, suggests that further investigation is warranted rather than assuming they are normal.
B) The patient may have a metabolic condition causing him to feel cold: Thin skin and non-elastic turgor can be indicative of aging, but the sensation of always feeling cold may point to an underlying metabolic condition, such as hypothyroidism or poor circulation, which can affect thermoregulation.

C) The patient has abnormal thinning of skin: While skin thinning is common in older adults, it is not necessarily "abnormal" in the context of aging. However, in conjunction with other symptoms like non-elastic turgor and cold sensitivity, it may warrant further evaluation.

D) The patient should have elastic turgor: In older adults, it is common to see decreased elasticity and turgor of the skin. Therefore, expecting the patient to have elastic turgor may not be appropriate, as it reflects the natural aging process rather than a healthy standard.

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Which instructions should the nurse provide a client to assess the lateral flexion?

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Naxlex Comprehensive Predictor Exams

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

Correct Answer is B

Explanation

The nurse assessing a 90-year-old patient notes that his skin is thin and turgor is non-elastic. The patient states that he always seems to be cold. What does the nurse know about these assessment findings?

Correct Answer is B

Explanation

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