During an admission assessment, the nurse observes the presence of kyphosis on an older adult female client with a history of osteoporosis. Which action should the nurse take in response to this finding?

Notify the healthcare provider.

Observe muscle fasciculations.

Document the assessment finding.

Palpate the area for an effusion.

Answer and Explanation

The Correct Answer is C

A. Notify the healthcare provider. Notifying the healthcare provider might be necessary if the kyphosis is a new finding or is associated with pain, neurological symptoms, or other complications. However, kyphosis is often a chronic condition associated with osteoporosis.

B. Observe muscle fasciculations. Muscle fasciculations are not directly related to kyphosis and osteoporosis. This option does not address the primary concern of the assessment finding.

C. Document the assessment finding. Documenting the presence of kyphosis is essential for the medical record and ongoing management of the client's osteoporosis. It ensures that the condition is noted and can be monitored over time.

D. Palpate the area for an effusion. Effusions are related to fluid accumulation in joints or tissues, which is not directly related to kyphosis. This is not an appropriate action in response to observing kyphosis.

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Correct Answer is D

Explanation

A. Mother's use of alcohol, drugs, or cigarettes during pregnancy: While this information might be relevant to the child's medical history, it's not directly related to planning care for the umbilical hernia repair surgery itself.

B. List of achievement timeline for developmental milestones: This information might be helpful for a general paediatric assessment, but it's not crucial for planning care specific to an umbilical hernia repair.

C. A history of rubella, rubeola, or chicken pox: Unless there are complications related to these illnesses, they are not directly relevant to the surgery.

D. Reactions to any previous hospitalizations: This information is vital. Knowing how the child reacted to previous hospitalizations (anaesthesia, medications, separation anxiety) can help the nurse anticipate potential challenges and develop strategies to create a positive experience for the child.

A. "I cough a lot at night and it keeps me up half the night." B. "I sleep on three pillows at night." C. " have multiple attacks of wheezing almost daily." D. "It doesn't take much activity before I'm out of breath."

Correct Answer is B

Explanation

A. "I cough a lot at night and it keeps me up half the night." Night-time coughing can be associated with various conditions, including asthma, GERD, or postnasal drip, but it is not specifically indicative of orthopnoea.

B. "I sleep on three pillows at night." This supports orthopnoea, which is difficulty breathing when lying flat. Clients with orthopnoea often use multiple pillows to elevate their upper body to alleviate shortness of breath.

C. "I have multiple attacks of wheezing almost daily." Frequent wheezing is more indicative of asthma or other obstructive airway diseases, not orthopnoea.

D. "It doesn't take much activity before I'm out of breath." This describes dyspnoea on exertion, which is different from orthopnoea, as it refers to difficulty breathing during physical activity rather than when lying down.

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During an admission assessment, the nurse observes the presence of kyphosis on an older adult female client with a history of osteoporosis. Which action should the nurse take in response to this finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A six-year-old girl is being admitted to the hospital for repair of an umbilical hernia. Which information, collected by the admitting nurse, is particularly helpful in planning care for this child?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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