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
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) Talking in a loud voice: While this may indicate some level of distress or confusion, it does not necessarily signal a specific neurological deficit. Clients may raise their voice for various reasons unrelated to neurological issues.
B) Grimacing with movement: This could suggest discomfort or pain but is not an explicit indicator of neurological impairment. Grimacing can occur for many reasons, including musculoskeletal issues or emotional responses, and does not specifically necessitate a focused neurological assessment.
C) Asymmetry of the client's smile: This finding is significant and raises concerns about potential neurological issues, such as a stroke or Bell's palsy. Facial asymmetry may indicate weakness or dysfunction in the cranial nerves responsible for facial movement, warranting a more thorough neurological examination to assess for underlying causes.
D) Inability to follow directions: While this may point to confusion or cognitive impairment, it is a more general indicator and could result from various factors, including anxiety or lack of understanding. It does not specifically highlight a localized neurological deficit as clearly as facial asymmetry does.
Correct Answer is C
Explanation
A) Anterior to the elbow: This term describes a location in front of the elbow. While it indicates a direction, it does not specifically address the vertical relationship of the discomfort in relation to the elbow. Since the client described discomfort "above" the elbow, this term is not the most accurate choice.
B) Distal to the elbow: The term "distal" refers to a location that is farther away from the trunk of the body or point of reference. Given that the discomfort is described as being above the elbow, this term is incorrect, as it would imply the discomfort is located toward the hand rather than toward the shoulder.
C) Proximal to the elbow: This term correctly indicates a location closer to the trunk of the body and specifically suggests that the discomfort is situated above the elbow, making it the most appropriate medical terminology to use in this context. It accurately reflects the relationship of the discomfort to the elbow.
D) Inferior to the elbow: "Inferior" refers to a location below another point of reference. Since the discomfort is described as above the elbow, this terminology would not apply and would misrepresent the location of the client’s discomfort.