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Cognitive Ability: AnalyzingClient Needs: Health Promotion and MaintenanceIntegrated Process: Nursing Process/AssessmentContent Area: Adult Health/MusculoskeletalAwarded 1.0 points out of 1.0 possible points.61.61.ID: 9477073978A nurse in the emergency department is performing a musculoskeletal assessment of a client. The presence of which of the following conditions would cause the nurse to avoid testing range of motion(ROM) of the cervical spine?A. HeadacheB. Neck trauma CorrectC. Sinus infectionD. Muscle spasmsRationale: A nurse performing a musculoskeletal assessment would not test ROM in a client who has sustained neck trauma, which may have resulted in a cervical fracture. If a cervical fracture is present, further movement of the neck could result in spinal cord injury. ROM testing does not need to be avoided if the client is experiencing a headache, sinus infection, or muscle spasms.Test-Taking Strategy: Use the process of elimination and note the strategic word “avoid” in the query
of the question. This word indicates a negative event query and the need to select the unsafe action.Noting the relationship between the words “cervical spine” in the question and “neck” will direct you the correct option. Review: the procedure for musculoskeletal assessment .References: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical management for positive outcomes (8th ed., p. 1951). St. Louis: Saunders.Perry, A., & Potter, P. (2010). Clinical nursing skills & techniques (7th ed., p. 161). St. Louis: Mosby.Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Adult Health/MusculoskeletalAwarded 1.0 points out of 1.0 possible points.62.62.ID: 9477077898A nurse reviewing the healthcare record of a client notes documentation of grade 4 muscle strength. The nurse understands that this indicates:is described as full ROM against gravity with full resistance. Grade 4 indicates good strength and fullROM against gravity with some resistance. Grade 3 indicates fair strength and full ROM with gravity.
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