A nurse in a family health clinic is collecting data as part of a routine physical examination of a client who is about to enter high school. The nurse observes an abnormal lateral curvature of the spine. The nurse should expect the provider to document which of the following disorders?
Scoliosis
Ankylosis
Kyphosis
Lordosis
The Correct Answer is A
A. Scoliosis: Scoliosis is characterized by an abnormal lateral curvature of the spine, commonly detected during routine physical exams in school-aged children and adolescents. This is the correct diagnosis for the described symptom.
B. Ankylosis: Ankylosis refers to joint stiffness or immobility due to fusion of the bones, not a lateral curvature of the spine. It is typically associated with conditions like ankylosing spondylitis and does not describe a spinal curvature.
C. Kyphosis: Kyphosis involves an abnormal forward curvature of the spine, often resulting in a hunchback appearance. It is not the same as a lateral curvature and thus does not fit the description given.
D. Lordosis: Lordosis is characterized by an exaggerated inward curve of the lower spine, commonly referred to as swayback. It does not involve lateral curvature and therefore is not relevant to the described condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Low-pitched cry: A high-pitched cry, not a low-pitched one, is more typical of increased ICP in infants. A low-pitched cry is not a common sign of ICP and may be more related to other conditions.
B. Positive Babinski reflex: The Babinski reflex is normal in infants up to about 1 year of age and is not indicative of increased ICP. It is a normal finding and not specific to increased intracranial pressure.
C. Insomnia: Infants with increased ICP may exhibit irritability and changes in sleeping patterns, but insomnia (difficulty sleeping) is not a classic symptom. The focus should be on other more specific signs like changes in cry and physical appearance.
D. Bulging fontanel: A bulging fontanel is a key sign of increased ICP in infants. It occurs due to pressure within the skull causing the soft spot on the head to protrude. This is a classic symptom of increased intracranial pressure in infants.
Correct Answer is D
Explanation
A. "I will immediately report irregular respirations." Irregular respirations can be normal in infants, as their breathing patterns are often irregular. Immediate reporting is not typically necessary unless there are other signs of distress.
B. "I will immediately report a respiratory rate of 28." A respiratory rate of 28 is low for a 1-month-old infant, but immediate reporting depends on the overall clinical picture and other signs of distress. Normal respiratory rates for this age are usually between 30-60 breaths per minute.
C. "I will count the baby's respirations for 30 seconds and multiply by two." While this method is used for older children and adults, it’s not ideal for infants due to their irregular breathing patterns. Counting for a full minute provides a more accurate assessment.
D. "I will count the baby's respirations by observing abdominal movements." This is correct. In infants, respiration is primarily diaphragmatic, making abdominal movements a reliable indicator of respiratory rate.
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