Nokea
An infant had a repair of a myelomeningocele two days ago. Which assessment is most important to detect a problem commonly seen following myelomeningocele repair?
- A. Bowel sounds
- B. Pulse oximetry
- C. Blood pressure in all four extremities
- D. Head circumference
Correct Answer: D
Rationale: Hydrocephalus is a common complication post-myelomeningocele repair due to altered cerebrospinal fluid flow; measuring head circumference detects this by identifying increased intracranial pressure.
You may also like to solve these questions
An adult is admitted to the psychiatric unit with a severe phobia. She develops severe anxiety when she crosses any type of bridge. She can no longer go to work or go shopping at the mall. The day after admission, she develops a panic attack and refuses to go to occupational therapy because she has to cross a bridge-like structure to go from one area of the hospital to another. How should the nurse respond to this situation?
- A. Accompany the client as she goes to occupational therapy
- B. Request that she be excused from occupational therapy until she is less anxious
- C. Have a staff member walk her to occupational therapy by a different route that does not cross a bridge-like structure
- D. Tell her that facing her fears is the only way to conquer them and that the nurse will help her do that
Correct Answer: C
Rationale: Using an alternate route avoids triggering the phobia, allowing participation in therapy while respecting her current anxiety level.
A nurse is teaching a patient about the use of albuterol (Proventil) for asthma. Which of the following instructions should be included?
- A. Use this medication daily to prevent asthma attacks.
- B. Use this medication only when you feel short of breath.
- C. Use this medication at bedtime.
- D. Use this medication before exercise.
Correct Answer: D
Rationale: Albuterol, a rescue inhaler, is used before exercise to prevent exercise-induced bronchospasm. It’s not for daily prevention, symptom-only use, or bedtime dosing.
Teaching the client with gonorrhea how to prevent reinfection and further spread is an example of:
- A. primary prevention.
- B. secondary prevention.
- C. tertiary prevention.
- D. primary health care prevention.
Correct Answer: B
Rationale: Secondary prevention targets the reduction of disease prevalence and disease morbidity through early diagnosis and treatment. Physiological Adaptation
A nurse is caring for a patient with major depressive disorder. Which of the following interventions is most appropriate?
- A. Encourage the patient to spend time alone
- B. Discourage the patient from expressing feelings
- C. Encourage participation in group activities
- D. Avoid discussing the patient's feelings
Correct Answer: C
Rationale: Group activities promote socialization and reduce isolation in depression, supporting recovery. Encouraging alone time or avoiding feelings worsens symptoms, and expression should be encouraged therapeutically.
When teaching adolescents about sexually transmitted diseases, what should the nurse emphasize that is the most common infection?
- A. Gonorrhea
- B. Chlamydia
- C. Herpes
- D. HIV
Correct Answer: B
Rationale: Chlamydia. It has the highest incidence among sexually transmitted diseases, requiring emphasis on prevention.