A nurse assesses neck movement of an adult and documents that the client's neck muscles are within expected limits if the client:
a. Is unable to resist the nurse's attempt to move the head upright.
b. Bends the head to the right and left (ear to shoulder) 15 degrees.
c. Flexes chin toward the chest 45 degrees.
d. Hyperextends the head 30 degrees from midline.
ANS: C
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During a pelvic examination the nurse notes the vaginal walls are pale. Which is the possible cause for this clinical manifestation?
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A) To implement evidence-based practice B) To ensure the order follows hospital policy C) To be sure interventions are individualized D) To be sure the intervention is safe