A nurse is assisting a client with range-of-motion exercises of the neck. Which of the following terms should the nurse use when documenting the client touching her chin to her chest?
Hyperextension
Lateral flexion
Rotation
Flexion
The Correct Answer is D
A. Hyperextension
Hyperextension refers to bending backward beyond the normal range.
B. Lateral flexion
Lateral flexion involves bending the neck to the side, ear toward shoulder.
C. Rotation
Rotation refers to turning the head side-to-side (e.g., shaking head “no”).
D. Flexion
Touching the chin to the chest is flexion of the neck-bending forward.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
A. Loss of calcium from bone matrix
Immobility causes bone demineralization, increasing the risk for osteoporosis and fractures.
B. Stasis of respiratory secretions
Lack of movement decreases chest expansion, leading to retained secretions and risk of pneumonia or atelectasis.
C. Increased cardiac workload
Immobilization leads to venous stasis and reduced venous return, increasing cardiac workload and risk of thromboembolism.
D. Decreased circulation from pressure
Prolonged pressure leads to reduced perfusion, increasing risk for pressure ulcers.
E. Increased mental activity
Immobilization often results in decreased mental stimulation, potentially leading to depression or confusion, especially in older adults.
Correct Answer is C
Explanation
A. Raise the head of the bed to 30 to 45 degrees.
While head elevation for comfort is acceptable, it is not the primary responsibility for CPM care.
B. Elevate the machine at the foot of the bed on one pillow.
The CPM machine should lie flat along the bed frame. Elevation on a pillow can cause misalignment or malfunction.
C. Set the proper flexion and extension limits.
The nurse must confirm that the machine is set according to the provider's orders for proper range of motion and to prevent injury.
D. Keep the operated knee warm.
While comfort is important, this is not a priority of CPM machine care and doesn't directly relate to its function.
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