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 B
Explanation
A) This would indicate pitting edema: Tenting is not indicative of pitting edema, which is characterized by a depression left in the skin after pressure is applied. Tenting specifically refers to the skin's elasticity and is assessed by pinching the skin, observing how quickly it returns to its normal position.
B) This may indicate dehydration, but might not be reliable in an older adult: Tenting is often a sign of dehydration, as it reflects decreased skin elasticity. However, in elderly individuals, skin changes due to aging (like reduced elasticity and moisture) may make this assessment less reliable. Factors such as medications, health status, and overall skin integrity can also influence this observation, making it necessary to consider other indicators of hydration.
C) This means the client is well hydrated: Tenting does not indicate adequate hydration. In fact, it typically suggests the opposite, as well-hydrated skin should return to normal quickly after being pinched.
D) This indicates peripheral neuropathy: While peripheral neuropathy can affect skin and tissue integrity, tenting specifically relates to skin turgor and elasticity rather than nerve function. Tenting is not a direct indicator of neuropathy; other assessments would be needed to evaluate nerve health.
Correct Answer is D
Explanation
A) Symmetry of lesions: While asymmetry can be a concern when assessing moles, it is not the most critical indicator when a lesion has already shown signs of burning and bleeding. Symmetry is one aspect of the overall assessment but does not immediately indicate danger in this scenario.
B) Border regularity: Irregular borders can suggest malignancy; however, the presence of burning and bleeding is a more pressing sign that warrants immediate attention. While border irregularity is important to assess, it is not as concerning as changes in color or the presence of symptoms like bleeding.
C) Diameter less than 6 mm: A diameter less than 6 mm is generally considered a normal size for moles and is not indicative of malignancy on its own. In this case, the burning and bleeding of the mole are more significant findings that raise concern, regardless of its size.
D) Color variation: Color variation in a pigmented lesion is a significant danger sign, as it can indicate changes that may suggest malignancy, especially when combined with other concerning symptoms like burning and bleeding. Variability in color may indicate the presence of different cell types and is a key factor in assessing the risk of melanoma.