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 D
Explanation
A) Inflammation of the lamina of the involved vertebra: While inflammation can contribute to pain, it is not the primary cause in the context of a herniated disc. The pain associated with a herniated disc is typically related to nerve compression rather than inflammation of the lamina itself.
B) Shifting of two adjacent vertebrae out of alignment: This describes a different condition, such as spondylolisthesis. A herniated disc primarily involves the displacement of disc material, rather than a significant misalignment of the vertebrae.
C) Increased pressure of cerebral spinal fluid within the vertebral column: Increased cerebrospinal fluid pressure is not typically associated with herniated discs and does not directly cause the pain related to this condition.
D) Compression of the spinal cord by the extruding disc: This is the most accurate explanation for the patient's pain. A cervical herniated disc can protrude and compress nearby nerve roots or the spinal cord itself, leading to significant pain, weakness, and other neurological symptoms. This compression is the primary cause of pain in patients with this diagnosis.
Correct Answer is A
Explanation
A) VII: The facial nerve (cranial nerve VII) is responsible for controlling the muscles of facial expression. By assessing facial symmetry and movement, the nurse evaluates the integrity and function of this nerve, which is crucial for activities such as smiling, frowning, and raising eyebrows.
B) V: The trigeminal nerve (cranial nerve V) is primarily responsible for sensation in the face and motor functions such as chewing. While it plays a role in facial movement, it does not specifically assess facial expressions.
C) III: The oculomotor nerve (cranial nerve III) controls eye movement and pupil constriction. It does not directly influence facial expressions, so it is not the nerve being assessed in this context.
D) VI: The abducens nerve (cranial nerve VI) is responsible for lateral eye movement. It is unrelated to facial expression or symmetry and is not the focus of this assessment.