The nurse is caring for a client whose recent health history includes an altered LOC. What should be the nurse's first action when assessing this client?

Assessing the client's verbal response.

Assessing the client's response to pain.

Assessing the client's judgment.

Assessing the client's ability to follow complex commands.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Assessing the client's verbal response is the first step in evaluating their level of consciousness (LOC). It provides immediate information about their ability to communicate and follow commands.

Choice B rationale

Assessing the client's response to pain is a later step in the LOC assessment if the client does not respond to verbal stimuli. It helps determine the level of consciousness if the client is not verbally responsive.

Choice C rationale

Assessing the client's judgment is part of a cognitive assessment but is not the first action when assessing LOC. It evaluates higher brain functions, not the initial level of responsiveness.

Choice D rationale

Assessing the client's ability to follow complex commands is part of a cognitive assessment and provides information about higher brain function but is not the first step in LOC assessment.

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Correct Answer is B

Explanation

Choice A rationale

Lordosis is an exaggerated inward curvature of the lumbar spine. It is commonly seen in pregnant women, individuals with obesity, or those with weak abdominal muscles. Lordosis is not characterized by an increased thoracic curvature.

Choice B rationale

Kyphosis is an exaggerated outward curvature of the thoracic spine, often resulting in a hunched or rounded back. It is commonly seen in older adults due to osteoporosis, degenerative disc disease, or poor posture. Kyphosis is the correct diagnosis for increased thoracic curvature.

Choice C rationale

Scoliosis is a lateral curvature of the spine, often resembling an "S" or "C" shape when viewed from behind. It can occur in any part of the spine but does not specifically describe an increased thoracic curvature.

Choice D rationale

Epiphyses refer to the growth plates at the ends of long bones in children and adolescents. They are not related to spinal curvature or any spinal disorder. .

A. Scoliosis. B. Muscular dystrophy. C. Kyphosis. D. Lordosis.

Correct Answer is A

Explanation

Choice A rationale

Scoliosis is characterized by a lateral curvature of the spine, often identified by uneven shoulders and a prominent scapula. The forward bending test accentuates these physical signs, helping to diagnose scoliosis.

Choice B rationale

Muscular dystrophy involves progressive muscle weakening and wasting, typically symmetrical, not causing the asymmetry seen in scoliosis. It usually doesn't present with the specific spinal curvature of scoliosis.

Choice C rationale

Kyphosis involves a forward rounding of the upper back, not a lateral curvature. It presents as a hunched or rounded back rather than uneven shoulders and prominent scapula.

Choice D rationale

Lordosis refers to an exaggerated inward curve of the lower back, not involving uneven shoulders or scapula. It affects the lumbar spine rather than presenting the scoliosis-related signs described.

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The nurse is caring for a client whose recent health history includes an altered LOC. What should be the nurse's first action when assessing this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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