Nokea
A 14-year-old girl is in the intensive care unit after a spinal cord injury 2 days ago. What nursing intervention is a priority for this child?
- A. Minimizing environmental stimuli
- B. Administering immunoglobulin
- C. Monitoring and maintaining systemic blood pressure
- D. Discussing long-term care issues with the family
Correct Answer: C
Rationale: Monitoring and maintaining blood pressure is critical in spinal cord injury due to physiologic lability and risks like autonomic dysreflexia. Stimuli minimization and immunoglobulin aren?t needed, and long-term care discussions are premature during acute stabilization.
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A recommendation to prevent neural tube defects (NTDs) is the supplementation of what?
- A. Vitamin A throughout pregnancy
- B. Folic acid for all women of childbearing age
- C. Folic acid during the first and second trimesters of pregnancy
- D. Multivitamin preparations as soon as pregnancy is suspected
Correct Answer: B
Rationale: Folic acid supplementation for women of childbearing age, especially preconceptionally, reduces NTD incidence significantly, as defects occur early (3-5 weeks). Vitamin A is unrelated, and supplementation only during pregnancy or with multivitamins is less effective.
The nurse is preparing a staff education in-service session for a group of new graduate nurses who will be working in a long-term care facility for children; many of the children have cerebral palsy (CP). What statement should the nurse include in the training?
- A. Children with dyskinetic CP have a wide-based gait and repetitive movements.
- B. Children with spastic pyramidal CP have a positive Babinski sign and ankle clonus.
- C. Children with hemiplegia CP have mouth muscles and one lower limb affected.
- D. Children with ataxic CP have involvement of pharyngeal and oral muscles with dysarthria.
Correct Answer: B
Rationale: Spastic pyramidal CP is characterized by a positive Babinski sign and ankle clonus due to hypertonicity. Dyskinetic CP involves oral muscles and dysarthria, hemiplegia affects one side with upper limbs more impacted, and ataxic CP features a wide-based gait.
The nurse is caring for a family whose infant was just born with anencephaly. What is the most important nursing intervention?
- A. Implement measures to facilitate the attachment process.
- B. Help the family cope with the birth of an infant with a fatal defect.
- C. Prepare the family for extensive surgical procedures that will be needed.
- D. Provide emotional support so the family can adjust to the birth of an infant with problems.
Correct Answer: B
Rationale: Anencephaly, a fatal neural tube defect, requires nursing support to help families cope with grief and provide comfort measures for the infant, who may survive briefly. Attachment is encouraged but secondary, no surgical options exist, and general support is less specific.
An 8-year-old child is hospitalized with infectious polyneuritis (Guillain-Barré syndrome [GBS]). When explaining this disease process to the parents, what should the nurse consider?
- A. Paralysis is progressive with little hope for recovery.
- B. Disease is inherited as an autosomal, sex-linked, recessive gene.
- C. Disease results from an apparently toxic reaction to certain medications.
- D. Muscle strength slowly returns, and most children recover.
Correct Answer: D
Rationale: GBS involves progressive paralysis with recovery of muscle strength starting within 2-3 weeks, with most children regaining full strength, especially younger ones. It?s immune-mediated, not inherited or medication-induced, and has a good prognosis.
Gingivitis is a common problem in children with cerebral palsy (CP). What preventive measure should be included in the plan of care?
- A. High-carbohydrate diet
- B. Meticulous dental hygiene
- C. Minimum use of fluoride
- D. Avoidance of medications that contribute to gingivitis
Correct Answer: B
Rationale: Meticulous dental hygiene prevents gingivitis in CP, countering enamel defects, high-carbohydrate diets, and spasticity-related oral care challenges. Fluoride use is encouraged, and medications like phenytoin may require hygiene adjustments, not avoidance.