The nurse is preparing to assess a client's spine for abnormalities. The nurse would ask the client to do which of the following steps to gather the most information with this assessment?
1. Sit down, then stand as the nurse looks from the front of the client.
2. Stand, bend back slowly, then to the right and left while the nurse looks from the back.
3. Bend over, stand tall, and stretch arms over the head.
4. Sit down, then lean forward and dangle the arms at the sides of the body.
2
Rationale 1: The client should be asked to stand during this assessment. This will allow the nurse to assess for symmetry.
Rationale 2: The spine should be visually inspected by viewing the back of the client. The client should be asked to stand during this assessment. This will allow the nurse to assess for symmetry. The spine should appear straight when viewed from the back.
Rationale 3: Bending and stretching will not illicit the needed information about the spine. Range of motion and flexibility may be assessed by asking the client to bend over or stretch.
Rationale 4: The spine is assessed by asking the client to stand. The nurse will then visually assess the client from the back.
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