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. 3-year-old walking on tiptoes: While some children may walk on their tiptoes occasionally, it's not necessarily a cause for concern unless it's persistent or accompanied by other developmental delays.

B. 1.5-year-old attempting to scribble: This is a typical stage for exploring hand and finger movements, leading to early attempts at drawing.

C. 5-month-old with whole hand grasp: At this age, infants use their whole hand to grasp objects, which is a normal developmental step before developing a more refined pincer grasp.

D. 3.5-month-old with diminished Moro reflex. The Moro reflex is a normal reflex in newborns that typically disappears by around 4 to 6 months of age. A diminished or absent Moro reflex before this age could indicate neurological concerns or developmental delays. Referral to a healthcare provider is necessary for further evaluation.

A. Pupils equal, round, reacts to light (PERRL) B. Pupils equal, round, reacts to light, and accommodation (PERLA) C. Neurological status intact. D. Glasgow Coma Scale (GCS) of 15.

Correct Answer is A

Explanation

A. Pupils equal, round, reacts to light (PERRL) This notation accurately reflects the observed findings.

B. Pupils equal, round, reacts to light, and accommodation (PERLA) While it includes accommodation, there was no specific assessment of accommodation mentioned.

C. Neurological status intact. This is too vague and does not provide specific details about the pupils.

D. Glasgow Coma Scale (GCS) of 15. The GCS score indicates overall neurological function, not specific pupil findings.

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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

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