Prepare for the NCLEX-RN® by exploring optimal care for newly diagnosed scoliosis patients prescribed with braces. Discover the nurse’s crucial first step in managing this condition. Get informed and stay prepared for your nursing journey.
The nurse caring for a client newly diagnosed with scoliosis who is ordered to wear a brace. Which action should the nurse take first?
A. Auscultate lung and heart sounds
B. Measure the client’s shoulder levels
C. Obtain a physical therapy consultation
D. Refer the client to a community support group
Scroll down for the correct answer!
The correct answer to today’s NCLEX-RN® Question is…
A. Auscultate lung and heart sounds
Rationale: Scoliosis may cause abnormal chest anatomy which can decrease pulmonary capacity and compromise respiratory and cardiac function. Therefore, the nurse should begin by assessing the client’s vital signs and auscultating lung and heart sounds, taking note of any signs or symptoms of cardiopulmonary compromise, such as dyspnea, chest pain, blue-tinged extremities, increased blood pressure, or increased pulse.
Major Takeaway
The priority nursing goals for a client with scoliosis are to monitor for cardiopulmonary complications, provide supportive care during treatment, and provide psychosocial support. The nurse should begin by assessing the client’s vital signs and auscultating lung and heart sounds, noting any signs or symptoms of cardiopulmonary compromise, and immediately reporting dyspnea or chest pain, blue-tinged extremities, increased blood pressure, or increased pulse. Then, if the client is prescribed a brace, the nurse should measure and record their shoulder levels and the heights of their anterior and posterior superior iliac spines to help monitor the progression of their spinal curvature. Next, as prescribed, the nurse should collaborate with the physical therapist to provide exercises to promote strength, posture alignment, and balance. Lastly, the nurse should provide information about community resources, organizations, and local support groups.
Incorrect answer explanations
B. Measure the client’s shoulder levels
Rationale: If a client is prescribed a brace for scoliosis treatment, the nurse should measure and record their shoulder levels and the heights of their anterior and posterior superior iliac spines to monitor the progression of their spinal curvature. However, this is not the nurse’s priority action.
C. Obtain a physical therapy consultation
Rationale: In clients with scoliosis, the nurse will collaborate with the physical therapist to provide exercises to promote strength, posture alignment, and balance, as prescribed; however, this is not the nurse’s priority action.
D. Refer the client to a community support group
Rationale: A referral to a community support group is an important intervention to assist the client with scoliosis to cope with their diagnosis; however, this is not the nurse’s priority action.
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