Which instructions should the nurse provide a client to assess the lateral flexion?
"Attempt to rotate your head in a circular manner.""
"Lean your head to the side and attempt to touch your ear to your shoulder."
"Attempt to raise your shoulders up toward your ears."
"Tilt your head back and look at the ceiling."
The Correct Answer is B
A) "Attempt to rotate your head in a circular manner": This instruction is focused on rotation rather than lateral flexion. While rotation assesses different neck movements, it does not specifically evaluate lateral flexion.
B) "Lean your head to the side and attempt to touch your ear to your shoulder": This instruction directly assesses lateral flexion of the neck. It encourages the client to bend their head to the side, effectively demonstrating the range of motion in that direction.
C) "Attempt to raise your shoulders up toward your ears": This instruction assesses shoulder elevation and shrugging rather than lateral flexion of the neck. It does not provide information about the lateral movement of the head.
D) "Tilt your head back and look at the ceiling": This instruction assesses extension of the neck rather than lateral flexion. It evaluates the ability to move the head backward.
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View Related questions
Correct Answer is A
Explanation
A) Stiff neck and shoulder pain: This symptom is very common in clients with a herniated cervical disc. The herniation can lead to irritation or compression of nearby nerves, resulting in localized pain in the neck and shoulder region. Clients often report this discomfort as one of their primary concerns.
B) Cauda equina syndrome: This serious condition arises from compression of the cauda equina, which occurs in the lower lumbar region of the spine, not the cervical area. Therefore, it is not a typical symptom of a cervical disc herniation.
C) Changes in knee and ankle reflexes: These changes are more associated with lumbar spine issues. While cervical disc problems can affect reflexes, they typically do not present as changes in lower limb reflexes, which are primarily linked to lower back conditions.
D) Sciatica: This term usually refers to pain that radiates down the leg due to compression of the sciatic nerve, often associated with lumbar disc herniation. It is not a common symptom of cervical disc herniation, which affects the neck and upper extremities.
Correct Answer is B
Explanation
A) The patient's integumentary system is within normal limits for his age: While thinning skin and decreased turgor can be common in older adults, the specific combination of findings, including the patient feeling cold, suggests that further investigation is warranted rather than assuming they are normal.
B) The patient may have a metabolic condition causing him to feel cold: Thin skin and non-elastic turgor can be indicative of aging, but the sensation of always feeling cold may point to an underlying metabolic condition, such as hypothyroidism or poor circulation, which can affect thermoregulation.
C) The patient has abnormal thinning of skin: While skin thinning is common in older adults, it is not necessarily "abnormal" in the context of aging. However, in conjunction with other symptoms like non-elastic turgor and cold sensitivity, it may warrant further evaluation.
D) The patient should have elastic turgor: In older adults, it is common to see decreased elasticity and turgor of the skin. Therefore, expecting the patient to have elastic turgor may not be appropriate, as it reflects the natural aging process rather than a healthy standard.