A nurse is collecting data from an older adult client who has had some bone density loss. The nurse observes excessive forward curvature of the thoracic spine. The nurse should document this finding using which of the following terminology?

Kyphosis

Scoliosis

Lordosis

Ankylosis

Answer and Explanation

The Correct Answer is A

A. Kyphosis: Excessive forward curvature of the thoracic spine, commonly due to osteoporosis-related bone loss in older adults.

B. Scoliosis refers to a lateral curvature of the spine.

C. Lordosis: exaggerated inward curvature of the lumbar spine, often seen in pregnancy or obesity.

D. Ankylosis: abnormal stiffening or fusion of joints, unrelated to spinal curvature.

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Free Nursing Study Resources

Correct Answer is ["A","B","D"]

Explanation

A. Assess respiratory rate and rhythm. Changes in breathing pattern may indicate hypoxia, respiratory distress, or metabolic acidosis.

B. Pulse oximetry reading. Measures oxygen saturation, which is critical in assessing oxygenation and ventilation status.

C. Assess bowel sounds. While anxiety and stress can affect the gastrointestinal system, bowel sounds are not directly relevant in this situation.

D. Auscultate lung sounds. Important for identifying wheezing, crackles, or diminished breath sounds, which may indicate bronchospasm, fluid overload, or airway obstruction.

E. Determine two-point discrimination in the lower extremities. This test assesses neurological function, which is not a priority in a client presenting with respiratory distress and anxiety.

A. Examine the back before the general inspection of the skin. B. Note dry, flaky skin as an expected finding. C. Use a penlight to examine the back in greater detail. D. Pinch up a fold of skin to check for turgor.

Correct Answer is D

Explanation

A. Examine the back before the general inspection of the skin: Skin assessment should follow a general inspection.

B. Note dry, flaky skin as an expected finding: While common in older adults, it may indicate dehydration or dermatologic conditions.

C. Use a penlight to examine the back in greater detail: Penlights are typically used for darker areas (e.g., mouth, wounds), not flaky skin.

D. Pinch up a fold of skin to check for turgor: Assesses hydration status, which is important since dehydration contributes to dry, flaky skin.

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A nurse is collecting data from an older adult client who has had some bone density loss. The nurse observes excessive forward curvature of the thoracic spine. The nurse should document this finding using which of the following terminology?

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Naxlex Comprehensive Predictor Exams

A client presents with complaints of anxiety, restlessness, and increased work of breathing. Which assessments should the nurse perform? (Select all that Apply)

Correct Answer is ["A","B","D"]

Explanation

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Correct Answer is D

Explanation

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