A nurse is assisting with screening a client for scoliosis. Which of the following actions should the nurse ask the client to perform?
Bend forward with back parallel to the floor.
Stand facing the nurse.
LIe supine with arms extended above head
Lie in a side-lying position.
The Correct Answer is A
A. Bend forward with back parallel to the floor: The forward bend test, or Adam’s test, allows the nurse to observe for asymmetry of the ribs or spine, which are common indicators of scoliosis. This position accentuates spinal curvature for easier assessment.
B. Stand facing the nurse: Observing the client from the front does not provide a clear view of spinal curvature or asymmetry of the shoulders, ribs, or scapulae, which are key findings in scoliosis screening.
C. Lie supine with arms extended above head: This position is not effective for detecting spinal curvature or rib asymmetry, as scoliosis is best visualized with the client standing and bending forward.
D. Lie in a side-lying position: The side-lying (lateral) position is used for assessing pressure ulcers or administering enemas, but it does not provide the necessary alignment or visual access to detect the "S" or "C" curve of the spine characteristic of scoliosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Ask the family if they want to participate in postmortem care: Allowing the family to choose whether to participate respects their cultural, spiritual, and personal preferences. This promotes dignity for both the client and family and provides an opportunity for closure.
B. Let the head of the client's bed flat: The client’s head should typically be elevated slightly to prevent discoloration of the face and to maintain a natural appearance for viewing. Flat positioning can cause facial edema or pooling of blood, which may be distressing to the family.
C. Place medical equipment to the side of the client's bed: While removing or repositioning equipment can help create a more comfortable viewing environment, it is not the first or most essential step in preparing for postmortem care.
D. Remove the client's dentures to close their mouth: Dentures should usually be left in place to maintain the natural shape of the face unless instructed otherwise. Removing them can cause the mouth to appear sunken, which may be distressing to the family.
Correct Answer is D
Explanation
A. “I am so relieved the baby looks like my mother.”: Feeling relief or comfort when noticing family resemblance in the newborn is a common emotional response. It generally reflects normal adjustment and bonding with the baby and does not indicate emotional distress requiring further evaluation.
B. “My appetite has really increased.”: Increased appetite postpartum can be a normal physiological response, especially with breastfeeding, as the body requires additional calories. It does not usually indicate a mental health concern or a need for further evaluation.
C. “My labor was so long. I'm glad it's over.”: Expressing relief or fatigue after a prolonged labor is a typical postpartum response. It shows processing of the birth experience and adjustment to recovery and newborn care, which does not warrant immediate concern.
D. “I really wish I had a girl instead.”: Expressing regret or disappointment regarding the baby’s sex may indicate difficulty bonding, gender preference stress, or emerging postpartum mood disturbances. This statement warrants further assessment for postpartum depression, anxiety, or adjustment issues to ensure maternal-infant wellbeing.
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