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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Irregular bones have complex shapes that do not fit into the other categories (long, short, or flat bones). They include bones such as the vertebrae and facial bones, which have specialized functions but are not primarily responsible for protecting vital organs.
Choice B rationale
Flat bones, such as the sternum, ribs, and skull bones, are designed to protect vital organs. They provide broad surfaces for muscle attachment and serve as protective barriers for organs like the brain, heart, and lungs.
Choice C rationale
Long bones, such as the femur and humerus, are primarily responsible for supporting the weight of the body and facilitating movement. While they contribute to the overall structure of the body, they are not specifically designed for organ protection.
Choice D rationale
Short bones, such as the carpals and tarsals, provide support and stability with limited movement. They are not primarily involved in the protection of vital organs.
Correct Answer is B
Explanation
Choice A rationale
Normal posture involves relaxed and symmetrical positioning of the limbs without any abnormal flexion or extension.
Choice B rationale
Decorticate posturing is characterized by abnormal flexion of the upper extremities at the elbows and wrists, and extension of the lower extremities, often indicating damage to the corticospinal tract.
Choice C rationale
Decerebrate posturing involves extension and outward rotation of both the arms and legs, indicating damage to the brain stem, which is more severe than decorticate posturing.
Choice D rationale
Flaccid posture refers to a complete lack of muscle tone and resistance, often seen in severe cases of neurological damage or after a stroke. .
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