A school nurse is screening children for scoliosis. Which assessment findings should the nurse expect to observe for scoliosis?
Unequal waist angles.
Complaints of a sore back.
Inability to bend at the waist.
An uneven hemline.
Asymmetry of the shoulders.
Correct Answer : A,D,E
The correct answers are choices A, D, and E. Unequal waist angles, an uneven hemline, and asymmetry of the shoulders.
Choice A rationale:
Unequal waist angles can be an indication of scoliosis, a condition characterized by abnormal lateral curvature of the spine. When the spine curves, it can cause one side of the waist to appear higher than the other, leading to unequal waist angles. This is a key physical finding in scoliosis assessment.
Choice B rationale:
Complaints of a sore back are a non-specific symptom and may not directly indicate scoliosis. While scoliosis can sometimes cause discomfort or pain, it's not the primary assessment finding that the nurse should expect to observe.
Choice C rationale:
Inability to bend at the waist is not a typical assessment finding of scoliosis. Scoliosis primarily involves the lateral curvature of the spine, which can lead to visible asymmetry and postural changes rather than restrictions in bending.
Choice D rationale:
An uneven hemline can be a sign of scoliosis. When the spine curves, it can cause the hips and shoulders to become misaligned, leading to changes in the alignment of clothing and accessories, such as an uneven hemline.
Choice E rationale:
Asymmetry of the shoulders is a common manifestation of scoliosis. One shoulder may appear higher than the other due to the lateral curvature of the spine. This asymmetry is often more noticeable when the child is viewed from behind.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C: Concrete operations stage.
Choice A rationale:
The preoperational stage, which occurs roughly between ages 2 and 7, is characterized by egocentrism, animism, and a lack of conservation. Children in this stage struggle with understanding that quantities can remain the same even if their appearance changes. For instance, they might think that pouring water from a tall glass into a short, wide glass somehow changes the amount of water. This stage does not demonstrate the mental understanding required for the examples given in the question.
Choice B rationale:
The intuitive thought stage, which typically spans from ages 4 to 7, is marked by increased symbolic thinking but still lacks the capacity for logical and systematic reasoning. Children in this stage might be able to count and perform basic arithmetic, but they struggle with more complex operations and understanding the underlying principles of mathematical operations. This stage is not where the ability to understand the given math operations is firmly established.
Choice C rationale:
The concrete operations stage, which encompasses ages 7 to 11, is characterized by the development of logical and systematic thinking. Children in this stage are capable of understanding basic mathematical principles and operations, such as conservation of quantity and simple arithmetic. They can mentally manipulate numbers and understand that reversing an operation will yield the original quantity. Therefore, this stage is when the ability to understand that 1 + 3 = 4 and 4 - 3 = 1 occurs.
Choice D rationale:
The formal operations stage, typically beginning around age 11, is characterized by abstract and hypothetical thinking. This is when adolescents and adults can engage in complex reasoning and consider multiple possibilities and outcomes. The given math operations are not the focus of this stage; rather, it pertains to more advanced cognitive abilities like hypothetical problem-solving and deductive reasoning.
Correct Answer is C
Explanation
The correct answer is choice C. Activity intolerance related to generalized weakness.
Choice A rationale:
Risk for injury related to depressed sensorium. This choice is not the most appropriate nursing diagnosis for a child with moderate anemia. While anemia can lead to fatigue and weakness, the main concern is the child's ability to tolerate physical activities, not the risk of injury due to a depressed sensorium.
Choice B rationale:
Decreased cardiac output related to abnormal hemoglobin. This choice is not the most suitable nursing diagnosis for a child with moderate anemia. While abnormal hemoglobin levels can affect cardiac output, moderate anemia typically doesn't lead to such a significant decrease in cardiac output that it becomes the primary nursing diagnosis. Activity intolerance is a more relevant concern.
Choice C rationale:
Activity intolerance related to generalized weakness. This is the most appropriate nursing diagnosis for a child diagnosed with moderate anemia. Moderate anemia results in a decrease in oxygen-carrying capacity, leading to generalized weakness and reduced ability to perform physical activities without becoming fatigued. The child's hemoglobin levels are likely low enough to cause noticeable activity intolerance.
Choice D rationale:
Risk for Injury related to dehydration and abnormal hemoglobin. This choice is not the best nursing diagnosis for a child with moderate anemia. Dehydration may exacerbate the effects of anemia, but the primary issue here is the anemia itself causing weakness and activity intolerance, which are better addressed with the choice C diagnosis.
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