The client presents with an exaggeration of the lumbar spine curve. How does the nurse interpret this finding?

Scoliosis.

Lordosis.

Kyphosis.

Dowager's hump.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Scoliosis refers to a lateral curvature of the spine, not an exaggeration of the lumbar spine curve, which is characterized by lordosis.

Choice B rationale

Lordosis is an exaggerated inward curve of the lumbar spine, often referred to as swayback. This condition is identified by the nurse as the client presents with an exaggerated lumbar curve.

Choice C rationale

Kyphosis describes an excessive outward curvature of the thoracic spine, resulting in a hunched back, not the lumbar spine.

Choice D rationale

Dowager's hump is a term commonly associated with kyphosis, characterized by a pronounced curvature of the upper back, not the lumbar region.

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Correct Answer is A

Explanation

Choice A rationale

The brain stem controls vital functions, including respiration. Damage to the brain stem, especially the medulla oblongata, can impair respiratory control, leading to the need for mechanical ventilation.

Choice B rationale

The parietal lobe is responsible for sensory processing and does not directly influence respiratory functions. Damage here would more likely affect sensation and spatial awareness.

Choice C rationale

The occipital lobe is primarily responsible for visual processing. Injury to this area would result in visual deficits rather than impaired respiration.

Choice D rationale

The frontal lobe is involved in cognitive functions, voluntary movement, and speech production, but it does not control respiration. Damage here would affect higher cognitive functions and motor planning.

A. Administer a bolus of normal saline as prescribed. B. Administer bronchodilators as prescribed and monitor the client's LOC. C. Increase the client's bed height and reassess in 30 minutes. D. Inform the care team and assess for further signs of possible increased ICP.

Correct Answer is D

Explanation

Choice A rationale

Administering a bolus of normal saline may not directly address the cause of increased respiratory effort, which could be related to increased intracranial pressure (ICP). Normal saline administration is not the priority intervention in this case.

Choice B rationale

Bronchodilators are used to manage bronchoconstriction, not increased respiratory effort due to potential increased ICP. Monitoring the client's level of consciousness (LOC) is important, but bronchodilators are not indicated here.

Choice C rationale

Increasing the client's bed height can help with respiratory effort, but it does not directly address the potential underlying issue of increased ICP. Reassessing in 30 minutes might delay necessary interventions.

Choice D rationale

Increased respiratory effort in a client with a head injury may indicate rising ICP. Informing the care team and assessing for further signs of increased ICP is crucial for timely intervention to prevent further complications.

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The client presents with an exaggeration of the lumbar spine curve. How does the nurse interpret this finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who has suffered a stroke is unable to maintain respiration and is intubated and placed on mechanical ventilator support. What portion of the brain is most likely responsible for the inability to breathe?

Correct Answer is A

Explanation

The nurse is caring for a client who sustained a moderate head injury following a bicycle accident. The nurse's most recent assessment reveals that the client's respiratory effort has increased. What is the nurse's most appropriate action?

Correct Answer is D

Explanation

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