The nurse is examining an elderly client and notes an exaggerated curvature of the thoracic spine.
The nurse should document this finding as which of the following?

Choice A rationale

Scleroderma is a chronic autoimmune disorder characterized by hardening and tightening of the skin and connective tissues. While it affects the skin, it is unrelated to emphysema and bronchitis, making it an unlikely finding in this client.

Choice B rationale

Pedal erythema, or redness of the feet, can result from various causes, including infections, allergies, and circulatory issues. However, it is not commonly associated with emphysema and bronchitis, making it an unlikely finding in this client.

Choice C rationale

Anasarca is generalized body swelling due to fluid retention, often seen in severe heart failure, liver disease, and kidney failure. While this condition involves significant swelling, it is not typically linked to emphysema and bronchitis.

Choice D rationale

Clubbing of the nails is a common finding in chronic respiratory conditions like emphysema and bronchitis. It involves bulbous enlargement of the fingertips and nail curvature, resulting from prolonged low oxygen levels, making it a likely finding in this client.

Choice A rationale

The optic nerve (CN II) is responsible for vision. It transmits visual information from the retina to the brain. Dysfunction in this nerve typically results in visual disturbances such as loss of vision, visual field defects, or difficulty in distinguishing colors. It does not control the movement or strength of the tongue.

Choice B rationale

The abducens nerve (CN VI) innervates the lateral rectus muscle of the eye, which is responsible for abducting the eye (moving it outward). Dysfunction in this nerve can lead to strabismus (misalignment of the eyes), double vision, or inability to move the eye outward. It does not affect tongue movement or strength.

Choice C rationale

The hypoglossal nerve (CN XII) innervates the muscles of the tongue, controlling its movement and strength. Dysfunction in this nerve can result in difficulty protruding the tongue, poor strength against resistance, and impaired speech or swallowing. Therefore, the symptoms described in the question indicate a dysfunction of the hypoglossal nerve.

Choice D rationale

The vestibulocochlear nerve (CN VIII) is responsible for hearing and balance. It transmits sound and equilibrium information from the inner ear to the brain. Dysfunction in this nerve can lead to hearing loss, tinnitus, vertigo, or balance problems. It does not control tongue movement or strength.