The nurse assesses the spine of a 12-year-old client and observes that one shoulder is higher than the other shoulder. Which should the nurse implement next? (Select all that apply.)
1. Assist the client to bed.
2. Check spinal alignment.
3. Determine height of hips.
4. Document spinal lordosis.
5. Instruct client to stand tall.
6. Refer client to chiropractor.
2, 3, 5
2. When shoulders are at uneven heights, the client potentially has scoliosis of the spine, a lateral curvature. The nurse makes additional observations to confirm the conclusion, including observing the alignment of the spine; the spine should be a straight line when viewed posteriorly.
3. The nurse also observes the level of the hips because the hips tilt in a contralateral deflection of the shoulders; if the left shoulder is down, the left hip will be higher than the right hip.
5. The client potentially alters the levels of the shoulders and hips by shifting body weight to one side; if the client has a straight spine, the hips and shoulders should be at even heights.
1. The client with scoliosis is not necessarily at increased risk for injury and bed rest is not indicated.
4. The spinal deformity is potentially scoliosis; lordosis is an abnormal curvature of the lumbar spine.
6. Referring the client to a chiropractor is premature and outside the scope of practice for the nurse.
You might also like to view...
A couple discusses their childbirth preparation options with the nurse. They want the father to be actively involved, and for the mother to avoid medications during the birthing process. The nurse's best response is
1. "The hospital will follow your wishes." 2. "The Leboyer method will provide what you want." 3. "The Bradley method will fit your needs." 4. "The Lamaze method will be easy to follow."
A patient's primary care provider has indicated that her symptoms of dyspnea and fatigue related to heart failure are class IV. This classification indicates that she experiences
a. symptoms with any activity or even at rest. b. symptoms with ordinary physical activity and has a slight limitation of physical activity. c. no symptoms with ordinary physical activity. d. symptoms with ordinary physical activity and has a marked limitation of physical activity.
The nurse planning discharge needs for a client with macular degeneration and type 1 diabetes mellitus should include which of the following in this client's discharge needs?
1. Information on assisted living facilities 2. Information on Medic-Alert bracelets 3. Referral to home care to ensure safety with administering insulin at home 4. Information on the need to have routine eye examinations every 5 years
The most important reason for displaying the ìNo Smokingî sign when oxygen is in use is to prevent
a. moisture b. lung disorders c. fire d. coughing