The nurse is examining an elderly client and notes an exaggerated curvature of the thoracic spine.
The nurse should document this finding as which of the following?

Lordosis.

Scoliosis.

Spinal dysplasia.

Kyphosis.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Lordosis refers to an excessive inward curvature of the lumbar spine, often referred to as swayback. This condition causes the lower back to arch more than normal, leading to a prominent abdomen and buttocks. Lordosis does not affect the thoracic spine and does not cause an exaggerated curvature in that region.

Choice B rationale

Scoliosis is a lateral curvature of the spine that results in an S- or C-shaped curve. It can occur in the thoracic, lumbar, or cervical regions of the spine. Scoliosis involves a sideways deviation rather than an exaggerated curvature in the thoracic spine.

Choice C rationale

Spinal dysplasia is a broad term that refers to various congenital abnormalities affecting the development of the spine. It includes conditions such as spina bifida, kyphosis, and scoliosis, each with distinct characteristics. The term itself does not specify an exaggerated thoracic curvature.

Choice D rationale

Kyphosis is an exaggerated outward curvature of the thoracic spine, resulting in a rounded or hunched back appearance. This condition is common in elderly individuals and can be caused by factors such as osteoporosis, vertebral fractures, or degenerative changes. It leads to a noticeable forward bend of the upper back.

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Correct Answer is A

Explanation

Choice A rationale

The sides of the mouth being symmetric when the patient smiles indicate intact function of the facial cranial nerve (CN VII). This nerve controls the muscles responsible for facial expressions, including smiling, frowning, and closing the eyes. Symmetry in these actions suggests that the facial nerve is functioning properly and that there is no nerve damage or weakness.

Choice B rationale

The patient's eyes moving to the left, right, up, down, and obliquely during conversation are functions of the oculomotor nerve (CN III), trochlear nerve (CN IV), and abducens nerve (CN VI), not the facial cranial nerve (CN VII). These nerves work together to control the movements of the eye muscles, enabling the eyes to move in different directions and maintain proper alignment.

Choice C rationale

Periodic blinking of the eyelids involves the oculomotor nerve (CN III) and the facial nerve (CN VII). The oculomotor nerve controls the muscles that lift the eyelid, while the facial nerve controls the muscles that close the eyelid. Blinking is a coordinated action involving both nerves, but the observation alone is not sufficient to determine the integrity of CN VII.

Choice D rationale

The patient moistening the lips with the tongue involves the function of the hypoglossal nerve (CN XII), which controls the movements of the tongue. The hypoglossal nerve is responsible for the motor control of most of the tongue muscles, allowing for actions like licking the lips, speaking, and swallowing. It is not related to the facial cranial nerve (CN VII).

A. Decreased angle between the cuticles and the nails. B. Upward curving of the nails. C. Blue nails. D. Angle of nails > 160 degrees.

Correct Answer is D

Explanation

Choice A rationale

A decreased angle between the cuticles and the nails is not indicative of clubbing. In fact, it is often associated with healthy nails. Clubbing is recognized by changes that increase the angle between the nail bed and the cuticle.

Choice B rationale

An upward curving of the nails, known as koilonychia or spoon nails, is not characteristic of clubbing but is often associated with iron-deficiency anemia. Hence, this answer is incorrect for clubbing.

Choice C rationale

Blue nails indicate cyanosis, which is related to a lack of oxygen in the blood. This is distinct from clubbing, which is more about the shape and angle of the nails rather than their color.

Choice D rationale

Clubbing is recognized by an increase in the angle between the nail bed and the cuticle, often greater than 160 degrees. This is a hallmark feature and the correct indicator of clubbing.

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The nurse is examining an elderly client and notes an exaggerated curvature of the thoracic spine.The nurse should document this finding as which of the following?

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Naxlex Comprehensive Predictor Exams

While taking a history, the nurse observes that the patient's facial cranial nerves (CN VII) are intact based on which behaviors of the patient?

Correct Answer is A

Explanation

A nurse is performing an assessment on the fingers and toes of a patient.What finding is consistent with clubbing?

Correct Answer is D

Explanation

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The nurse is examining an elderly client and notes an exaggerated curvature of the thoracic spine.
The nurse should document this finding as which of the following?