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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Hypoparathyroidism is not associated with exophthalmos. Hypoparathyroidism is a condition where the parathyroid glands produce insufficient parathyroid hormone, leading to low calcium levels in the blood. This condition doesn't directly affect the thyroid gland or cause exophthalmos.
Choice B rationale:
Exophthalmos, also known as protruding or bulging eyes, is a classic symptom of hyperthyroidism. Hyperthyroidism is a condition where the thyroid gland produces excessive amounts of thyroid hormones. These elevated hormone levels can lead to a variety of symptoms, including increased metabolism, weight loss, nervousness, and protruding eyes due to inflammation of the eye muscles and tissues behind the eye.
Choice C rationale:
Hyperparathyroidism involves the overactivity of the parathyroid glands, leading to excessive production of parathyroid hormone (PTH) and elevated calcium levels in the blood. While elevated calcium levels can have various effects on the body, exophthalmos is not a typical manifestation of hyperparathyroidism. The condition is more commonly associated with bone and kidney issues.
Choice D rationale:
Hypothyroidism, the underproduction of thyroid hormones by the thyroid gland, is not linked to exophthalmos. Instead, hypothyroidism is known for causing symptoms such as fatigue, weight gain, cold intolerance, and slow heart rate. Exophthalmos is a characteristic sign of hyperthyroidism, not hypothyroidism.
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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