A nurse is collecting data from an older adult client who has had some bone density loss. The nurse observes excessive forward curvature of the thoracic spine. The nurse should document this finding using which of the following terminology?

Kyphosis

Scoliosis

Lordosis

Ankylosis

Answer and Explanation

The Correct Answer is A

A. Kyphosis: Excessive forward curvature of the thoracic spine, commonly due to osteoporosis-related bone loss in older adults.

B. Scoliosis refers to a lateral curvature of the spine.

C. Lordosis: exaggerated inward curvature of the lumbar spine, often seen in pregnancy or obesity.

D. Ankylosis: abnormal stiffening or fusion of joints, unrelated to spinal curvature.

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Correct Answer is B

Explanation

A. Amber color. Normal urine color ranges from pale yellow to deep amber, depending on hydration. Amber urine alone is not abnormal.

B. White blood cells (WBC) 10. Normal WBC levels in urine should be ≤5 per high-power field (HPF). A count of 10 WBCs suggests infection or inflammation, such as a urinary tract infection (UTI).

C. pH 5.0. Normal urine pH ranges from 4.5 to 8.0, so a pH of 5.0 is within normal limits and does not require reporting.

D. Occasional casts. Occasional hyaline casts are normal, especially with dehydration or vigorous exercise. However, cellular casts (e.g., red blood cell casts) could indicate kidney disease.

A. Apply cornstarch to keep the skin dry. B. Reposition the client every 3 hr. C. Massage bony prominences to promote circulation. D. Provide the client with a diet high in protein.

Correct Answer is D

Explanation

A. Apply cornstarch to keep the skin dry. Cornstarch can cause skin irritation or promote bacterial/fungal growth, which increases the risk of breakdown rather than preventing it.

B. Reposition the client every 3 hr. Clients at risk for skin breakdown should be repositioned at least every 2 hours to relieve pressure and prevent pressure ulcers.

C. Massage bony prominences to promote circulation. Massaging bony prominences can cause tissue damage and increase the risk of pressure ulcers instead of preventing them.

D. Provide the client with a diet high in protein. Protein is essential for skin repair and maintenance, helping prevent breakdown and promote healing.

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A nurse is collecting data from an older adult client who has had some bone density loss. The nurse observes excessive forward curvature of the thoracic spine. The nurse should document this finding using which of the following terminology?

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