A nurse is assisting with screening a client for scoliosis. Which of the following actions should the nurse ask the client to perform?
Bend forward with back parallel to the floor.
Stand facing the nurse.
LIe supine with arms extended above head
Lie in a side-lying position.
The Correct Answer is A
A. Bend forward with back parallel to the floor: The forward bend test, or Adam’s test, allows the nurse to observe for asymmetry of the ribs or spine, which are common indicators of scoliosis. This position accentuates spinal curvature for easier assessment.
B. Stand facing the nurse: Observing the client from the front does not provide a clear view of spinal curvature or asymmetry of the shoulders, ribs, or scapulae, which are key findings in scoliosis screening.
C. Lie supine with arms extended above head: This position is not effective for detecting spinal curvature or rib asymmetry, as scoliosis is best visualized with the client standing and bending forward.
D. Lie in a side-lying position: The side-lying (lateral) position is used for assessing pressure ulcers or administering enemas, but it does not provide the necessary alignment or visual access to detect the "S" or "C" curve of the spine characteristic of scoliosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
A. Encourage prolonged dangling before ambulation: While dangling at the bedside can help prevent orthostatic hypotension, the client is already ambulating independently without reported dizziness or hypotension. Prolonged dangling is unnecessary and does not address the current issues of urinary discomfort and bowel cramping.
B. Encourage oral fluid intake: Adequate hydration helps maintain urine flow, prevent catheter obstruction, and support bowel function. Encouraging fluids also helps dilute urine, reducing bladder irritation and the risk of infection, which is especially important post-prostatectomy.
C. Assist the client with a sitz bath: A sitz bath can relieve perineal discomfort, reduce pain, and promote relaxation of the pelvic muscles. Given the client’s bladder fullness and postoperative cramping, this noninvasive intervention helps improve comfort and facilitate urination.
D. Irrigate indwelling catheter with 500 mL of fluid: Routine irrigation with such a large volume is not recommended and may cause trauma or introduce infection. Catheter irrigation should only be performed according to provider prescription and typically with small, prescribed amounts.
E. Administer an enema: The client reports only a single hard, painful bowel movement, and routine enema administration is not indicated. Enemas should be reserved for severe constipation or impaction, and inappropriate use can cause irritation or fluid shifts.
Correct Answer is ["125"]
Explanation
Total Volume: 1,000 mL
Infusion Time: 8 hours
- Calculate the infusion rate
Infusion Rate (mL/hr) = Total Volume ÷ Time (hr)
Infusion Rate = 1,000 ÷ 8
Infusion Rate = 125 mL/hr
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