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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View Related questions
Correct Answer is D
Explanation
A) Safety issues with an unsupervised resident in the lounge area: While there could be safety concerns related to a resident being in a common area at night, the primary outcome expected from continued insomnia would more directly relate to the individual's functioning rather than immediate safety issues.
B) Onset of cardiac dysfunction: While chronic sleep disturbances can contribute to various health problems, including cardiovascular issues, the immediate outcome of insomnia is more likely to be seen in daily functioning rather than a direct onset of cardiac dysfunction.
C) Onset of new underdiagnosed health problems: While ongoing insomnia may exacerbate existing health issues or lead to new ones over time, the most immediate and observable outcome of insomnia would relate to how it affects daily functioning rather than the development of new health problems.
D) The ability to function during the day may be hindered by these episodes: Insomnia typically leads to increased fatigue, decreased alertness, and impaired cognitive function during the day. As a result, the resident's overall ability to engage in daily activities and interact socially may be significantly hindered by their lack of restorative sleep.
Correct Answer is A
Explanation
A) Barrel Chest: This term describes a condition where the anterior-posterior (AP) diameter of the chest is equal to the transverse diameter, giving the chest a rounded appearance. This finding is often observed in older adults or individuals with chronic respiratory conditions, and it indicates a potential increase in lung volume and air trapping, commonly seen in conditions like emphysema or chronic obstructive pulmonary disease (COPD).
B) Chronic Obstructive Pulmonary Disease: While barrel chest can be associated with COPD, it is not a direct descriptor of the chest shape. COPD encompasses various symptoms and physiological changes but does not specifically define the chest's physical appearance as barrel-shaped.
C) Anterior/Posterior Distortion: This term does not accurately describe the findings observed in the assessment. While it suggests some alteration in chest shape, it does not specifically refer to the characteristic appearance of barrel chest, which is a well-defined clinical term.
D) Lordosis: This refers to an excessive inward curve of the spine, particularly in the lumbar region. While it may affect posture and overall body alignment, it does not relate to the chest shape or measurements, making it an inappropriate choice in this context.