The student nurse is assessing the client's lateral flexion. Which of the following instructions by the student to the client indicates the need for further instruction? Standard Text: Select all that apply
1. "Tilt your head back and look at the ceiling.".
2. "Lean your head to the side and attempt to touch your ear to your shoulder.".
3. "Touch your chin to your chest.".
4. "Attempt to raise your shoulders up toward your ears.".
5. "Attempt to rotate your head in a circular manner.".
1,3,4,5
Rationale 1: "Tile your head back and look at the ceiling.". Tilting the head back and looking toward the ceiling is an example of hyperflexion.
Rationale 2: "Lean your head to the side and attempt to touch your ear to your shoulder.". Lateral flexion can be assessed by tilting the head to each shoulder with the ear from the same side.
Rationale 3: "Touch your chin to your chest.". Flexion refers to movements that reduce the angle. Touching the chin to the chest would be an example of flexion.
Rationale 4: "Attempt to raise your shoulders up toward your ears.". Flexibility and mobility may be assessed by asking the client to raise and lower the shoulders but are not examples of methods to assess lateral flexion.
Rationale 5: "Attempt to rotate your head in a circular manner.". Flexibility and mobility may be assessed by asking the client to rotate the head but it is not an example of methods of lateral flexion.
You might also like to view...
The nurse is caring for a patient who is morbidly obese and who has been diagnosed with somatic symptom disorder. The patient history reveals that the patient's mother suffered from alcohol use disorder. Which domain does the nurse recognize as the most useful in explaining the patient's condition?
1. Cultural domain 2. Spiritual domain 3. Biological domain 4. Psychological domain
The focal point of nursing is the nurse-patient interaction. What must nurses consider when conducting the necessary assessment of their patients and significant others?
A) Their health disparities B) Their societal beliefs C) The subgroup they belong to D) Their own cultural orientation
Which statement by a mother about antiretroviral agents for the management for her 5-year-old child with acquired immunodeficiency syndrome (AIDS) indicates that she has a good understanding?
a. "When my child's pain increases, I double the recommended dosage of antiretroviral medication." b. "Addiction is a risk, so I only use the medication as ordered." c. "Doses of the antiretroviral medication are selected on the basis of my child's age and growth." d. "By the time my child is an adolescent she will not need her antiretroviral medications any longer."
The nurse would consider which of the following clients at greatest risk for hemolytic disease?
A) The mother has Rh-negative blood and the baby has Rh-positive blood. B) The mother and baby both have Rh-positive blood. C) The mother and baby have Rh-negative blood. D) The mother has Rh-positive blood and the baby has Rh-negative blood.