During the admission assessment of an older adult female, the nurse notes the presence of kyphosis. The client tells the nurse that she has a history of osteoporosis. To obtain additional information related to this finding, the nurse should question the client about what additional information in her history?

Decreased height.

Loss of appetite.

Weight gain.

Painful swallowing.

Answer and Explanation

The Correct Answer is A

A. Decreased height: Osteoporosis often leads to vertebral fractures, especially in the upper (thoracic) spine. These fractures can cause pain, height loss, and a stooped or hunched posture (kyphosis).

B. Loss of appetite: While osteoporosis itself does not directly cause loss of appetite, it’s essential to assess overall health and nutritional status. However, this symptom is not directly related to kyphosis.

C. Weight gain: Weight gain is not typically associated with osteoporosis or kyphosis. It is less relevant in this context.

D. Painful swallowing: Painful swallowing is not directly related to osteoporosis or kyphosis. It is less relevant in this context.

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Correct Answer is D

Explanation

A. Absolute dullness: This typically indicates fluid or a mass in the abdomen and is not a normal finding.

B. Absent sounds: Complete absence of bowel sounds can be a sign of an obstruction or ileus.

C. Pain: Pain during percussion suggests inflammation or irritation in the underlying organs.

D. Musical and drum like sounds: These are normal bowel sounds produced by gas and fluid movement within the intestines.

A. The gallbladder is normal. B. Deeper palpation technique is needed. C. The client is too obese. D. Palpating in the wrong abdominal quadrant.

Correct Answer is A

No explanation

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Naxlex Comprehensive Predictor Exams

The nurse completes percussion of the abdomen on an adult client. Which finding is considered normal?

Correct Answer is D

Explanation

While assessing a client who is obese, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. Which is the most likely explanation for failure to locate the gallbladder by palpation?

Correct Answer is A

A pregnant, homeless woman who has received no prenatal care presents to the clinic in her third trimester because she is having vaginal bleeding, but reports that she is not in pain. Ultrasound reveals a placenta previa. Which action should the nurse implement?

The nurse is conducting a functional assessment on an older adult client who is reporting decreased activity due to reduced energy and strength. Which action should the nurse perform during the functional assessment?

The nurse completes palpation of the thoracic region on an adolescent client. Which finding is considered normal for this adolescent client?

Which finding, obtained during a skin assessment of a student, should the school nurse report to the healthcare provider?

A six-year-old girl is being admitted to the hospital for repair of an umbilical hernia. Which information, collected by the admitting nurse, is particularly helpful in planning care for this child?

Which assessment finding supports the client statement, "My feet swell all the time?"

An older adult client who has been talking to the client's deceased mother is referred to the psychiatric clinic for an evaluation. Which assessment should the nurse complete first?

Which is the best approach for the nurse to use when interviewing a client about alcohol and substance use?