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    HESI RN HEALTH ASSESSMENT PROCTORED EXAM

    During an admission assessment, the nurse observes the presence of kyphosis on an older adult female client with a history of osteoporosis. Which action should the nurse take in response to this finding?

    Explanation & Rationale

    A. Notify the healthcare provider. Notifying the healthcare provider might be necessary if the kyphosis is a new finding or is associated with pain, neurological symptoms, or other complications. However, kyphosis is often a chronic condition associated with osteoporosis.B. Observe muscle fasciculations. Muscle fasciculations are not directly related to kyphosis and osteoporosis. This option does not address the primary concern of the assessment finding.C. Document the assessment finding. Documenting the presence of kyphosis is essential for the medical record and ongoing management of the client's osteoporosis. It ensures that the condition is noted and can be monitored over time.D. Palpate the area for an effusion. Effusions are related to fluid accumulation in joints or tissues, which is not directly related to kyphosis. This is not an appropriate action in response to observing kyphosis.

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