Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A school nurse is screening children for scoliosis. Which assessment findings should the nurse expect to observe for scoliosis?
A. Unequal waist angles.
Unequal waist angles can be an indication of scoliosis, a condition characterized by abnormal lateral curvature of the spine. When the spine curves, it can cause one side of the waist to appear higher than the other, leading to unequal waist angles. This is a key physical finding in scoliosis assessment.
B. Complaints of a sore back.
Complaints of a sore back are a non-specific symptom and may not directly indicate scoliosis. While scoliosis can sometimes cause discomfort or pain, it's not the primary assessment finding that the nurse should expect to observe.
C. Inability to bend at the waist.
Inability to bend at the waist is not a typical assessment finding of scoliosis. Scoliosis primarily involves the lateral curvature of the spine, which can lead to visible asymmetry and postural changes rather than restrictions in bending.
D. An uneven hemline.
An uneven hemline can be a sign of scoliosis. When the spine curves, it can cause the hips and shoulders to become misaligned, leading to changes in the alignment of clothing and accessories, such as an uneven hemline.
E. Asymmetry of the shoulders.
Asymmetry of the shoulders is a common manifestation of scoliosis. One shoulder may appear higher than the other due to the lateral curvature of the spine. This asymmetry is often more noticeable when the child is viewed from behind.
This question is an excerpt from Nurse Dive's nursing test bank - Pediatrics Midterm V1 2023 Test 3 Proctored Exam. Take the full exam now
Full Explanation
The correct answers are choices A, D, and E. Unequal waist angles, an uneven hemline, and asymmetry of the shoulders.
Choice A rationale:
Unequal waist angles can be an indication of scoliosis, a condition characterized by abnormal lateral curvature of the spine. When the spine curves, it can cause one side of the waist to appear higher than the other, leading to unequal waist angles. This is a key physical finding in scoliosis assessment.
Choice B rationale:
Complaints of a sore back are a non-specific symptom and may not directly indicate scoliosis. While scoliosis can sometimes cause discomfort or pain, it's not the primary assessment finding that the nurse should expect to observe.
Choice C rationale:
Inability to bend at the waist is not a typical assessment finding of scoliosis. Scoliosis primarily involves the lateral curvature of the spine, which can lead to visible asymmetry and postural changes rather than restrictions in bending.
Choice D rationale:
An uneven hemline can be a sign of scoliosis. When the spine curves, it can cause the hips and shoulders to become misaligned, leading to changes in the alignment of clothing and accessories, such as an uneven hemline.
Choice E rationale:
Asymmetry of the shoulders is a common manifestation of scoliosis. One shoulder may appear higher than the other due to the lateral curvature of the spine. This asymmetry is often more noticeable when the child is viewed from behind.
Similar Questions
What distinguishing manifestation of spasmodic croup should parents be taught to identify?
A. The child has a high fever.
Spasmodic croup is characterized by sudden-onset symptoms, including a barking cough, but it is not typically associated with a high fever. The barky cough is caused by inflammation and narrowing of the upper airways, leading to a distinct sound when the child coughs.
B. It has a harsh, barky cough.
A harsh, barky cough is a hallmark symptom of spasmodic croup. It is caused by the swelling of the vocal cords and the upper airway, resulting in the characteristic sound. This type of croup is often triggered by viral infections and is usually not bacterial in nature.
C. It is bacterial in nature.
Spasmodic croup is usually of viral origin rather than bacterial. Bacterial infections may lead to other respiratory conditions, but they are not a distinguishing feature of spasmodic croup.
D. Wheezing is heard audibly.
Wheezing is not a typical manifestation of spasmodic croup. Wheezing is often associated with lower airway conditions such as asthma, while croup primarily affects the upper airways and vocal cords, leading to the barking cough.
Full Explanation
The correct answer is choice B. It has a harsh, barky cough.
Choice A rationale:
Spasmodic croup is characterized by sudden-onset symptoms, including a barking cough, but it is not typically associated with a high fever. The barky cough is caused by inflammation and narrowing of the upper airways, leading to a distinct sound when the child coughs.
Choice B rationale:
A harsh, barky cough is a hallmark symptom of spasmodic croup. It is caused by the swelling of the vocal cords and the upper airway, resulting in the characteristic sound. This type of croup is often triggered by viral infections and is usually not bacterial in nature.
Choice C rationale:
Spasmodic croup is usually of viral origin rather than bacterial. Bacterial infections may lead to other respiratory conditions, but they are not a distinguishing feature of spasmodic croup.
Choice D rationale:
Wheezing is not a typical manifestation of spasmodic croup. Wheezing is often associated with lower airway conditions such as asthma, while croup primarily affects the upper airways and vocal cords, leading to the barking cough.
Which structural defects constitute tetralogy of Fallot?
A. Pulmonic stenosis, ventricular septal defect, aortic hypertrophy, left ventricular hypertrophy.
Pulmonic stenosis, ventricular septal defect, aortic hypertrophy, left ventricular hypertrophy. This choice is incorrect because it includes "aortic hypertrophy" and "left ventricular hypertrophy," which are not components of the tetralogy of Fallot. Aortic hypertrophy is not a recognized structural defect in tetralogy of Fallot, and left ventricular hypertrophy is not a characteristic feature of this congenital heart condition.
B. Pulmonic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy.
Pulmonic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy. This is the correct choice. Tetralogy of Fallot is characterized by four specific structural defects: pulmonic stenosis (narrowing of the pulmonary valve), ventricular septal defect (hole between the right and left ventricles), overriding aorta (aorta positioned over the ventricular septal defect, receiving blood from both ventricles), and right ventricular hypertrophy (enlargement of the right ventricle due to increased workload).
C. Aortic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy.
Aortic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy. This choice is incorrect because it includes "aortic stenosis," which is not part of the tetralogy of Fallot. In tetralogy of Fallot, the stenosis occurs at the pulmonary valve, not the aortic valve.
D. Aortic stenosis, atrial septal defect, overriding aorta, left ventricular hypertrophy.
Aortic stenosis, atrial septal defect, overriding aorta, left ventricular hypertrophy. This choice is incorrect. While "overriding aorta" is present in tetralogy of Fallot, "atrial septal defect" and "left ventricular hypertrophy" are not part of this condition. Atrial septal defects involve a hole between the two atria, not the ventricles, and left ventricular hypertrophy is not typically seen in tetralogy of Fallot.
Full Explanation
The correct answer is choice B: Pulmonic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy.
Choice A rationale:
Pulmonic stenosis, ventricular septal defect, aortic hypertrophy, left ventricular hypertrophy. This choice is incorrect because it includes "aortic hypertrophy" and "left ventricular hypertrophy," which are not components of the tetralogy of Fallot. Aortic hypertrophy is not a recognized structural defect in tetralogy of Fallot, and left ventricular hypertrophy is not a characteristic feature of this congenital heart condition.
Choice B rationale:
Pulmonic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy. This is the correct choice. Tetralogy of Fallot is characterized by four specific structural defects: pulmonic stenosis (narrowing of the pulmonary valve), ventricular septal defect (hole between the right and left ventricles), overriding aorta (aorta positioned over the ventricular septal defect, receiving blood from both ventricles), and right ventricular hypertrophy (enlargement of the right ventricle due to increased workload).
Choice C rationale:
Aortic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy. This choice is incorrect because it includes "aortic stenosis," which is not part of the tetralogy of Fallot. In tetralogy of Fallot, the stenosis occurs at the pulmonary valve, not the aortic valve.
Choice D rationale:
Aortic stenosis, atrial septal defect, overriding aorta, left ventricular hypertrophy. This choice is incorrect. While "overriding aorta" is present in tetralogy of Fallot, "atrial septal defect" and "left ventricular hypertrophy" are not part of this condition. Atrial septal defects involve a hole between the two atria, not the ventricles, and left ventricular hypertrophy is not typically seen in tetralogy of Fallot.
The nurse is caring for a school-age girl who has had a cardiac catheterization. The child tells the nurse that her bandage is "too wet." The nurse finds the bandage and bed soaked with blood. What is the most appropriate initial nursing action?
A. Place the child in the Trendelenburg position.
is wrong because placing the child in the Trendelenburg position is not an appropriate initial nursing action in this scenario. This position can increase intracranial pressure and is typically used for patients experiencing shock or hypotension.
B. Apply a new bandage with more pressure.
is wrong because applying a new bandage with more pressure might be a subsequent action, but the priority is to apply direct pressure to slow down the bleeding.
C. Notify the physician.
is wrong because notifying the physician is important, but the nurse should first take immediate action to control the bleeding and minimize potential harm to the patient.
D. Apply direct pressure above the catheterization site.
The first action should be to apply direct pressure above the catheterization site to help control the bleeding and minimize blood loss. This will also give the nurse time to prepare additional interventions or supplies if necessary.
Full Explanation
Answer is: d. Apply direct pressure above the catheterization site.
Explanation: The first action should be to apply direct pressure above the catheterization site to help control the bleeding and minimize blood loss. This will also give the nurse time to prepare additional interventions or supplies if necessary.
Choice a. is wrong because placing the child in the Trendelenburg position is not an appropriate initial nursing action in this scenario. This position can increase intracranial pressure and is typically used for patients experiencing shock or hypotension.
Choice b. is wrong because applying a new bandage with more pressure might be a subsequent action, but the priority is to apply direct pressure to slow down the bleeding.
Choice c. is wrong because notifying the physician is important, but the nurse should first take immediate action to control the bleeding and minimize potential harm to the patient.