The nurse is performing the physical examination of a client with a suspected neurologic disorder. In addition to assessing other parts of the body, the nurse should assess for neck rigidity.
Which method should help the nurse assess for neck rigidity correctly?
Gently pressing the bones on the neck.
Moving the head toward both sides.
Lightly tapping the lower portion of the neck to detect sensation.
Moving the head and chin toward the chest.
The Correct Answer is D
Choice A rationale
Pressing the bones on the neck does not adequately assess for rigidity and may cause discomfort without providing useful information about the neurologic status.
Choice B rationale
Moving the head toward both sides is a method used to assess range of motion but does not specifically assess for neck rigidity, which requires specific positioning and movement.
Choice C rationale
Lightly tapping the lower portion of the neck to detect sensation does not assess for rigidity; it may be used to test sensory function rather than muscular stiffness or tension.
Choice D rationale
Moving the head and chin toward the chest is the standard method to assess for neck rigidity, especially in cases of suspected meningitis. This movement can reveal stiffness or resistance, which are key indicators of neurologic involvement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Vitiligo is a condition characterized by depigmentation of the skin, leading to white patches. It does not typically affect the fingernails, so pitting on the surface of the nails is not indicative of vitiligo.
Choice B rationale
Psoriasis is a chronic skin condition that often affects the nails, leading to pitting or the appearance of small depressions on the nail surface. Nail psoriasis can also cause discoloration, thickening, and separation of the nail from the nail bed.
Choice C rationale
Melanoma is a type of skin cancer that can affect the nails, causing dark streaks or pigmentation changes. However, pitting on the surface of the nails is not a characteristic feature of melanoma.
Choice D rationale
Diabetes can lead to various nail changes, including thickening and yellowing of the nails, but it does not typically cause pitting on the nail surface. Pitting is more specific to psoriasis.
Correct Answer is B
Explanation
Choice A rationale
Temporal lobe damage affects auditory processing and memory rather than visual stimuli interpretation, impacting functions like language comprehension and memory formation.
Choice B rationale
Occipital lobe is the primary visual processing center of the brain, responsible for interpreting visual stimuli. Damage to this lobe impairs visual perception and recognition, aligning with the symptoms described.
Choice C rationale
Frontal lobe injury affects executive functions, behavior, and motor skills, not visual stimuli interpretation. Symptoms include problems with planning, movement, and personality changes rather than visual processing issues.
Choice D rationale
Parietal lobe processes sensory information such as touch, temperature, and pain, and helps in spatial orientation. It does not primarily interpret visual stimuli, making it less relevant to the described visual interpretation difficulty.
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