During the admission assessment of an older adult female, the nurse notes the presence of kyphosis. The client tells the nurse that she has a history of osteoporosis. To obtain additional information related to this finding, the nurse should question the client about what additional information in her history?

Decreased height.

Loss of appetite.

Weight gain.

Painful swallowing.

Answer and Explanation

The Correct Answer is A

A. Decreased height: Osteoporosis often leads to vertebral fractures, especially in the upper (thoracic) spine. These fractures can cause pain, height loss, and a stooped or hunched posture (kyphosis).

B. Loss of appetite: While osteoporosis itself does not directly cause loss of appetite, it’s essential to assess overall health and nutritional status. However, this symptom is not directly related to kyphosis.

C. Weight gain: Weight gain is not typically associated with osteoporosis or kyphosis. It is less relevant in this context.

D. Painful swallowing: Painful swallowing is not directly related to osteoporosis or kyphosis. It is less relevant in this context.

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Correct Answer is A

Explanation

A. Blue tinge in the nail beds: This finding is indicative of cyanosis. When oxygen levels in the blood are low, the skin and mucous membranes may appear bluish due to inadequate oxygenation. The nail beds are a common area to observe this bluish discoloration.

B. Ashen grey tone to lips: While this can be concerning, it is not a classic sign of cyanosis. Ashen grey lips may be associated with other conditions, such as shock or poor perfusion, but they do not specifically indicate cyanosis.

C. Ashy yellow appearance of skin: This finding is not related to cyanosis. An ashy yellow appearance may be seen in conditions like liver disease or jaundice, but it does not reflect oxygenation status.

D. Reddish purple colored palms: Again, this is not a sign of cyanosis. Reddish or purple palms may be seen in various conditions, but they do not specifically point to inadequate oxygen levels.

A. Compare measured circumferences of each extremity joint. B. Instruct the client to walk across the room and observe the gait. C. Perform passive range of motion and compare the findings. D. Measure the length of each leg and document the findings.

Correct Answer is D

No explanation

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Naxlex Comprehensive Predictor Exams

The nurse is assessing a darkly pigmented child for cyanosis. Which finding indicates cyanosis?

Correct Answer is A

Explanation

While assessing a client, the nurse notices that the client's legs are asymmetrical. Which additional physical data should the nurse collect?

Correct Answer is D

Which assessment technique should the nurse use to confirm the presence of papilledema in a client with a rapidly decreasing level of consciousness?

While counting the respirations of an adult client who is bedfast, the nurse observes that the client uses the sternocleidomastoid, trapezius, and abdominal muscles during respirations. Which action should the nurse take in response to this finding?

In assessing tactile fremitus in the client with suspected pneumonia, the nurse should perform which action?

A clinic nurse is assessing infants and toddlers for fine and gross motor development. Which child should the nurse refer to a healthcare provider for further evaluation?

In assessing an older adult client, the nurse notes that the client's right arm muscles feel soft and boggy. To gather additional data related to this finding, which assessment should the nurse complete next?

A client grimaces while preforming range of motion of the left knee during an annual health assessment. Which movements should the nurse utilize to assess the client's ability to normally perform range of motion on the right knee?

Gestational Ultrasound. In preparing the client for the procedure, the nurse should explain that the primary reason for conducting the ultrasound is to obtain which information?

An adolescent's mother calls the primary healthcare provider's office to Inquire about the results of her daughter's serum test results that were drawn last week. Since it is the teenager's 18th birthday, how should the nurse respond to this mother's inquiry?