While assessing a client's musculoskeletal status, the nurse asks the client to perform lateral bends. Which of the following will this movement provide information about?

Range of motion

Diaphragmatic excursion

Spinous processes

Spinal deformities

Answer and Explanation

The Correct Answer is A

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

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Correct Answer is C

Explanation

A) Hypoxia: Although the client's oxygen saturation is slightly decreased at 95% on room air, it is not critically low. Hypoxia could be a concern, but it is secondary to other more immediate issues, such as hypotension, that might be causing the low oxygen saturation.
B) Anemia: The client’s hemoglobin and hematocrit levels are low, indicating anemia. While anemia is a significant concern, it does not pose an immediate threat compared to hypotension, which can lead to more severe complications if not addressed promptly.
C) Hypotension: The client’s blood pressure is notably low at 82/58 mm Hg. Hypotension can lead to inadequate perfusion of vital organs and may be a result of or contribute to other issues such as sepsis or significant blood loss. Immediate attention to correcting hypotension is crucial to prevent further complications.
D) Pneumonia: The client presents with symptoms suggestive of pneumonia, including a productive cough, fever, and elevated white blood cell count. While pneumonia is a critical condition that requires treatment, addressing hypotension is a more urgent priority as it directly impacts the client's circulatory stability and overall well-being.

A. to check radial pulses B. to assess pedal pulses C. to assess jugular filling pressure D. to auscultate lung sounds

Correct Answer is C

Explanation

A) To check radial pulses: Radial pulses are typically assessed by palpation at the wrist. A gooseneck lamp is not necessary for this task; standard lighting and direct palpation are usually sufficient.
B) To assess pedal pulses: Pedal pulses are assessed by palpation on the top of the foot. A gooseneck lamp is not needed for this purpose, as the lighting conditions are generally adequate for palpation in a well-lit room.
C) To assess jugular filling pressure: Assessing jugular venous pressure (JVP) requires good lighting to clearly see the pulsations in the jugular veins. A gooseneck lamp provides focused and adjustable lighting, which is helpful for this assessment. This ensures accurate observation of the jugular veins and helps in evaluating the severity of heart failure.
D) To auscultate lung sounds: Auscultating lung sounds involves using a stethoscope and does not typically require a gooseneck lamp. Proper lighting is not essential for auscultation, as the focus is on auditory assessment rather than visual inspection.

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While assessing a client's musculoskeletal status, the nurse asks the client to perform lateral bends. Which of the following will this movement provide information about?

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Correct Answer is C

Explanation

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