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
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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Related Questions
Correct Answer is A
Explanation
helps train the body to respond to natural urges.
B. Immediately before meals. Although eating stimulates peristalsis, this is not the most effective approach because the client may not be ready to defecate at that time.
C. Every 2 hr day and night. A rigid 2-hour schedule is unnecessary and may cause distress or inconvenience for the client.
D. After every drink or meal. While eating may trigger the gastrocolic reflex, forcing bathroom visits after every meal or drink is not always appropriate.
Correct Answer is D
Explanation
A. Press the skin over the client's ankle bone. Skin over the bony prominences is not ideal for assessing turgor, as it may not accurately reflect dehydration.
B. Observe for non-blanching, pinpoint-size, red or purple spots on the skin of the abdomen. This describes petechiae, which is a sign of bleeding disorders, not hydration status.
C. Lightly palpate the skin using the fingertips. Palpation does not assess elasticity.
D. Grasp a fold of skin on the client's forearm or near the sternum. The best way to check for dehydration is by pinching the skin on the sternum or forearm and observing how quickly it returns to normal.
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