To assess for the presence of kyphosis, which action should the nurse take?

Review findings of client's bone density exam.

Observe the client's overall body posture.

Palpate joints for tenderness and edema.

Guide the client through active range of motion.

Answer and Explanation

The Correct Answer is B

Rationale:
A. Review findings of client's bone density exam: A bone density exam assesses for osteoporosis or osteopenia, which are risk factors for kyphosis, but it does not directly assess the presence or degree of spinal curvature. Observational examination is needed to identify kyphosis itself.

B. Observe the client's overall body posture: Kyphosis is characterized by an exaggerated outward curvature of the thoracic spine, leading to a hunched or stooped posture. Direct observation of the client’s posture provides the most accurate and immediate assessment of kyphosis during a physical examination.

C. Palpate joints for tenderness and edema: Palpating joints assesses for inflammation, arthritis, or localized joint disease. While these conditions can cause discomfort, they do not specifically evaluate spinal curvature or detect kyphosis.

D. Guide the client through active range of motion: Active range of motion assesses joint flexibility and mobility but does not primarily evaluate spinal alignment or postural abnormalities like kyphosis, which are better seen during standing posture observation.

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Correct Answer is D

Explanation

Rationale:
A. Multiple yellow lesions with a grainy surface: These may represent seborrheic keratoses, which are common, benign skin growths seen especially in older adults. They typically do not require urgent medical intervention unless changing rapidly or showing signs of malignancy.

B. Large, flat, dark red irregular area on the neck: This finding likely represents a port-wine stain, a type of vascular birthmark. While noticeable, it is generally benign and would not usually necessitate immediate reporting unless there are associated complications or sudden changes.

C. Multiple silver striae on the abdomen: Silver striae (stretch marks) are common and typically result from rapid changes in body size, such as during pregnancy, weight gain, or growth spurts. They are benign and do not require healthcare provider notification unless accompanied by concerning symptoms.

D. Bluish discoloration of the nailbeds: Cyanosis, indicated by bluish nailbeds, suggests decreased oxygenation or possible cardiovascular or pulmonary compromise. It is a significant clinical finding that warrants immediate reporting to the healthcare provider for further evaluation and management.

A. Dim the lights in the examination room. B. Question the client about steroid use. C. Continue with the cardiac examination. D. Position the client in high Fowler's position.

Correct Answer is C

Explanation

Rationale:
A. Dim the lights in the examination room: Dimming the lights can sometimes help during inspection for certain assessments, such as using transillumination, but it does not assist in palpating or auscultating an apical pulse. Lighting conditions are unrelated to detecting heart sounds or movement.

B. Question the client about steroid use: While steroid use in body-builders can have cardiovascular implications, questioning about steroid use does not immediately address the challenge of locating an apical pulse. Investigating steroid use would be important later but not the priority action during the assessment.

C. Continue with the cardiac examination: In very muscular individuals, the apical impulse can be difficult to palpate due to increased chest wall thickness. It is appropriate to proceed with auscultation of heart sounds instead, as this method does not rely on palpating the apical impulse and still assesses cardiac function effectively.

D. Position the client in high Fowler's position: Changing the client's position to high Fowler’s can improve breathing and heart auscultation in some cases but does not specifically enhance palpation of the apical pulse in heavily muscled individuals. Continuing with auscultation without changing the position is the best immediate step.

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To assess for the presence of kyphosis, which action should the nurse take?

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Naxlex Comprehensive Predictor Exams

When assessing a client's skin, which finding should the nurse report to the healthcare provider (HCP)?

Correct Answer is D

Explanation

When assessing a 24-year-old body-builder, the nurse is unable to palpate an apical pulse. Which action should the nurse implement?

Correct Answer is C

Explanation

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