Nokea
A nurse is collecting data from a child who has muscular dystrophy. Which of the following findings should the nurse expect? (Select all that Apply)
- A. Spinal defect and sac-like protrusion
- B. Muscular weakness in lower extremities
- C. Kyphosis of the lower spine
- D. Purposeless, involuntary, abnormal movements
- E. Unsteady waddling gait
Correct Answer: B,C,E
Rationale: Choice A rationale: Spinal defects and sac-like protrusions are not typically associated with muscular dystrophy. They are more commonly seen in conditions like spina bifida. Choice B rationale: Muscular weakness in the lower extremities is a common symptom of muscular dystrophy. This is due to the progressive degeneration of muscle fibers, which leads to weakness and loss of muscle mass. Choice C rationale: Kyphosis of the lower spine can be a complication of muscular dystrophy. As the muscles supporting the spine weaken, the spine can curve abnormally, leading to kyphosis. Choice D rationale: Purposeless, involuntary, abnormal movements are not typically associated with muscular dystrophy. These symptoms are more commonly seen in neurological conditions like Huntington's disease or certain types of cerebral palsy. Choice E rationale: An unsteady waddling gait is often seen in individuals with muscular dystrophy. This is due to the progressive weakness and loss of muscle mass in the lower extremities.
You may also like to solve these questions
A nurse working at a clinic speaks on the telephone with a parent of a 2-month-old infant. The parent tells the nurse that the infant has projectile vomiting followed by hunger after meals. Which of the following responses by the nurse is appropriate?
- A. Bring your infant into the clinic today to be seen.'
- B. Burp your child more frequently during feedings.'
- C. Give your infant an oral rehydrating solution.'
- D. You might want to try switching to a different formula.'
Correct Answer: A
Rationale: The symptoms described by the parent - projectile vomiting followed by hunger - could indicate a serious condition such as pyloric stenosis, which is a narrowing of the opening from the stomach to the small intestine. This condition can lead to severe dehydration and requires immediate medical attention. While burping can help to relieve gas and minor stomach discomfort, it would not address the underlying issue causing the projectile vomiting. This advice might be appropriate for a baby with simple colic or gas, but not for the symptoms described. While oral rehydrating solutions can help to replace lost fluids and electrolytes, they do not address the underlying cause of the projectile vomiting. Furthermore, if the baby is vomiting frequently, they may not be able to keep down the solution. Switching formulas can sometimes help babies who have allergies or intolerances to certain ingredients in their current formula. However, the symptoms described are not typical of a formula intolerance or allergy. Moreover, switching formulas without seeking medical advice can potentially lead to other complications.
A child has had a cast placed on his left arm following a diagnosed fracture. Which actions should the nurse take? (Select all that apply)
- A. Smooth the rough edges of the cast to maintain skin integrity
- B. Wear sterile gloves when touching or removing the cast
- C. Monitor capillary refill and color of nail beds of the left-hand
- D. Monitor for signs of pain
- E. Assess for numbness, tingling, or decreased sensation of the left hand.
Correct Answer: A,C,D,E
Rationale: Choice A rationale: Smoothing the rough edges of the cast can help maintain skin integrity and prevent skin irritation or injury. Choice C rationale: Monitoring capillary refill and color of nail beds of the left hand is important to assess the circulation to the hand and ensure that the cast is not too tight. Choice D rationale: Monitoring for signs of pain can help detect complications such as compartment syndrome, which is a serious condition that can occur if pressure within the muscles builds to dangerous levels. Choice E rationale: Assessing for numbness, tingling, or decreased sensation of the left hand is important as these can be signs of nerve damage or compression. Choice B rationale: Wearing sterile gloves when touching or removing the cast is not typically necessary. The outside of a cast is not a sterile environment, and healthcare providers do not usually wear sterile gloves when handling it.
A nurse at a pediatrician's office answers a phone call from a parent whose child just ingested 15 vitamin tablets with added ferrous sulfate. Which of the following instructions should the nurse give to the parent?
- A. Administer syrup of ipecac.
- B. Give the child 120 mL (8 oz) of orange juice.
- C. Contact the poison control center.
- D. Provide the child with a high-carbohydrate snack.
Correct Answer: C
Rationale: Administering syrup of ipecac is not recommended in cases of iron overdose. Ipecac was once used to induce vomiting in cases of poisoning, but it is no longer recommended due to potential complications and lack of evidence for effectiveness. Giving the child orange juice will not help in this situation. While vitamin C can enhance iron absorption, it does not have an effect on iron that has already been absorbed into the body. Contacting the poison control center is the appropriate action. They can provide immediate advice on what to do in cases of potential iron overdose. Providing a high-carbohydrate snack will not help in this situation. It will not affect the absorption or toxicity of the iron.
A nurse is contributing to the plan of care for a 5-week-old infant in the pediatric unit. The infant has been vomiting since week 2 of life and it has been progressively worse over the past 2 weeks. Parents report the vomiting is now forceful and projectile ('like a volcano erupting') immediately after every feeding, but the infant is eager to eat and seems to be constantly hungry. The infant has been receiving a cow's milk-based, iron-fortified formula since birth. The pediatrician reports the infant has not gained weight in the past 2 weeks. The last weight in the pediatrician's office is 3.54kg (8 lb). No other significant medical or surgical history. What condition is the client most likely experiencing and what actions should the nurse take to address that condition? What parameters should the nurse monitor to assess the client's progress?
- A. Gastroesophageal Reflux Disease (GERD), change the formula, monitor weight and feeding habits
- B. Pyloric Stenosis, refer for surgical consultation, monitor weight and vomiting frequency
- C. Lactose Intolerance, switch to lactose-free formula, monitor weight and stool consistency
- D. Milk Protein Allergy, switch to hypoallergenic formula, monitor weight and skin reactions
Correct Answer: B
Rationale: Gastroesophageal Reflux Disease (GERD) in infants is a condition where the stomach contents flow back into the esophagus causing discomfort. However, the symptoms described, such as projectile vomiting and constant hunger, are more consistent with Pyloric Stenosis. Pyloric Stenosis is a condition in infants where the opening from the stomach to the small intestine narrows, preventing food from entering the small intestine. The symptoms described by the parents, such as projectile vomiting after every feeding and constant hunger, align with this condition. The infant's lack of weight gain could be due to the fact that food is not being properly digested and absorbed. The nurse should refer the infant for a surgical consultation as the treatment for Pyloric Stenosis is usually surgical. The nurse should monitor the infant's weight and frequency of vomiting to assess the infant's progress. Lactose Intolerance in infants is a condition where the infant has difficulty digesting lactose, a sugar found in milk and dairy products. Symptoms can include gas, bloating, and diarrhea. However, the symptoms described by the parents do not align with this condition. Milk Protein Allergy in infants is a condition where the infant's immune system reacts negatively to the proteins in cow's milk. Symptoms can include hives, itching, wheezing, difficulty breathing, constipation, and bloody diarrhea. However, the symptoms described by the parents do not align with this condition.
A nurse is caring for a toddler whose parent states that the child has a mass in his abdominal area and his urine is a pink color. Which of the following actions is the nurse's priority?
- A. Schedule the child for an abdominal ultrasound.
- B. Instruct the parent to avoid pressing on the abdominal area.
- C. Determine if the child is having pain.
- D. Obtain a urine specimen for a urinalysis.
Correct Answer: B
Rationale: Schedule the child for an abdominal ultrasound. While an ultrasound may be necessary for further diagnosis, it is not the immediate priority. The child's symptoms suggest a possible Wilms' tumor, a type of kidney cancer that primarily affects children. An ultrasound can help confirm this diagnosis, but it should not be the first action. Instruct the parent to avoid pressing on the abdominal area. This is the correct answer. If the child has a Wilms' tumor, pressing on the abdominal area could potentially cause the cancer to spread. Therefore, it is crucial to avoid any unnecessary pressure on the abdomen until further medical evaluation can be performed. Determine if the child is having pain. While assessing for pain is an important part of nursing care, it is not the immediate priority in this situation. The child's symptoms need urgent medical attention, and assessing for pain will not provide the necessary information to guide immediate care. Obtain a urine specimen for a urinalysis. Although a urinalysis can provide valuable information about a patient's health, it is not the immediate priority in this situation. The child's symptoms suggest a possible Wilms' tumor, which requires immediate medical attention. A urinalysis may be part of the diagnostic process, but it should not be the first action taken.