During an admission assessment, the nurse observes the presence of kyphosis on an older adult female client with a history of osteoporosis. Which action should the nurse take in response to this finding?

Notify the healthcare provider.

Observe muscle fasciculations.

Document the assessment finding.

Palpate the area for an effusion.

Answer and Explanation

The Correct Answer is C

A. Notify the healthcare provider. Notifying the healthcare provider might be necessary if the kyphosis is a new finding or is associated with pain, neurological symptoms, or other complications. However, kyphosis is often a chronic condition associated with osteoporosis.

B. Observe muscle fasciculations. Muscle fasciculations are not directly related to kyphosis and osteoporosis. This option does not address the primary concern of the assessment finding.

C. Document the assessment finding. Documenting the presence of kyphosis is essential for the medical record and ongoing management of the client's osteoporosis. It ensures that the condition is noted and can be monitored over time.

D. Palpate the area for an effusion. Effusions are related to fluid accumulation in joints or tissues, which is not directly related to kyphosis. This is not an appropriate action in response to observing kyphosis.

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Correct Answer is A

Explanation

A. Cries vigorously when stimulated. A vigorous cry is a positive sign that the infant's lungs are functioning well and that they are receiving adequate oxygenation, indicating a good transition to extrauterine life.

B. Heart rate of 220 beats/minute. A heart rate of 220 beats/minute is too high for a newborn and could indicate tachycardia or distress, not a normal transition.

C. A positive Babinski reflex. A positive Babinski reflex is a normal finding in newborns but is not directly related to their immediate transition to extrauterine life. It is a neurological reflex that indicates normal nervous system function.

D. Flexion of all four extremities. Flexion of all four extremities is a good sign of normal muscle tone and neurological function but does not directly indicate respiratory or circulatory adaptation to extrauterine life as clearly as a vigorous cry does.

A. Triceps skin fold and mid-arm circumference. B. Twenty-four-hour food recall, preferences, and allergies. C. Weight loss history and body surface area (BSA) D. Body mass index (BMI) and serum albumin level.

Correct Answer is D

Explanation

A. Triceps skin fold and mid-arm circumference. These measurements can provide some indication of nutritional status, but they may not be as reliable in older adults due to changes in body composition and skin elasticity.

B. Twenty-four-hour food recall, preferences, and allergies. While dietary information is important, it may not accurately reflect the client's current nutritional status.

C. Weight loss history and body surface area (BSA). While weight loss history is relevant, BSA is not typically used to assess nutritional status.

D. Body mass index (BMI) and serum albumin level. BMI is a commonly used indicator of nutritional status, and serum albumin level reflects protein status, which is important for assessing malnutrition.

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During an admission assessment, the nurse observes the presence of kyphosis on an older adult female client with a history of osteoporosis. Which action should the nurse take in response to this finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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