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 C
Explanation
A. Peeling of the hands and feet: Desquamation of the hands and feet is commonly associated with conditions such as Kawasaki disease or scarlet fever during the healing phase. It is not a typical manifestation of pertussis.
B. Koplik spots: Koplik spots are small white lesions on the buccal mucosa that are characteristic of measles. They are not seen in pertussis and point toward a different viral illness.
C. Paroxysmal cough: Pertussis is characterized by severe, repetitive coughing spells that occur in rapid succession. These paroxysmal coughs may be followed by a high-pitched inspiratory “whoop” and can lead to vomiting or exhaustion.
D. Beefy, red tongue: A beefy red tongue is commonly associated with scarlet fever or other streptococcal infections. It is not a defining feature of pertussis.
Correct Answer is B
Explanation
A. Deliver 2 L of oxygen via partial nonrebreather mask: While supplemental oxygen may support oxygenation, it does not treat the underlying life-threatening allergic reaction. Oxygen alone is insufficient for anaphylaxis and should not delay definitive treatment.
B. Give epinephrine intramuscularly: Epinephrine is the first-line treatment for anaphylaxis and rapidly counteracts airway constriction, hypotension, and vascular permeability. Intramuscular administration in the mid-outer thigh provides rapid absorption and is essential to prevent respiratory compromise and shock.
C. Notify the radiology department: Notifying radiology is unrelated to the acute management of an allergic reaction. Immediate intervention to secure the airway and treat anaphylaxis takes priority over nonessential notifications.
D. Administer diazepam PO: Diazepam is an anxiolytic and has no role in managing anaphylaxis or airway obstruction. It does not reverse histamine-mediated effects and would delay critical emergency treatment.
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