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. FACES. The Wong-Baker FACES scale is used for children aged 3 years and older who can understand and select a face representing their pain level.

B. FLACC. The FLACC scale (Face, Legs, Activity, Cry, Consolability) is used for infants and nonverbal children to assess pain through observation of behaviors.

C. Visual Analog Scale. The Visual Analog Scale (VAS) requires the client to point on a numeric pain scale, which is inappropriate for infants who cannot communicate pain verbally.

D. Oucher. The Oucher scale is similar to FACES and is used in children aged 3–12 years. It relies on self-report, which is not feasible for a 6-month-old infant.

A. Relief of urinary retention B. Convenience for the nursing staff or the client's family C. Routine acquisition of a urine specimen D. Measurement of residual urine after urination E. Presence of an open perineal wound

Correct Answer is ["A","D","E"]

Explanation

A. Relief of urinary retention. Urinary catheterization is indicated for clients who cannot void effectively, which can lead to bladder distension and complications.

B. Convenience for the nursing staff or the client's family. Catheterization should never be done for staff convenience due to the high risk of infection (CAUTI - catheter-associated urinary tract infection).

C. Routine acquisition of a urine specimen. Routine urine specimens should be obtained through clean-catch or midstream methods, unless a sterile sample is required for culture and sensitivity testing.

D. Measurement of residual urine after urination. Catheterization may be needed to measure post-void residual volume in cases of urinary retention.

E. Presence of an open perineal wound. A catheter can help prevent urine contamination of an open wound in the perineal area, reducing the risk of infection.

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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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Naxlex Comprehensive Predictor Exams

A nurse is caring for a 6-month-old infant who is postoperative. Which of the following pain assessment scales should the nurse use to determine the infant's pain level?

Correct Answer is B

Explanation

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Correct Answer is ["A","D","E"]

Explanation

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