Question

The nurse is preparing to assess the spine of an older adult. Which actions will the nurse take during this assessment? Select all that apply.

A. Observe the client walk away and then return
B. Ask the client to bend backward
C. Assess for crepitus
D. Measure height
E. Ask the client to bend forward at the waist

Answer 1

During the assessment of the spine in an older adult, the nurse will observe the client's gait, ask them to perform specific movements, assess for joint problems, measure their height, and evaluate their spinal alignment.

Step-by-step explanation:

During the assessment of the spine in an older adult, the nurse will take the following actions:

1. Observe the client walk away and then return: This allows the nurse to assess the client's gait and mobility.
2. Ask the client to bend backward: This helps to assess for any limitations or pain in the spine.
3. Assess for crepitus: Crepitus refers to a grating or crackling sound or sensation that may occur during movement and can indicate joint problems.
4. Measure height: Measuring height can help monitor for any changes in spinal alignment or posture.
5. Ask the client to bend forward at the waist: This helps to assess for any spinal deformities or asymmetry.