Nokea
Daya's child is scheduled for surgerydue to myelomeningocele; the primary reason for surgical repair is which of thefollowing?
- A. To prevent hydrocephalus
- B. To reduce the risk of infection
- C. To correct the neurologic defect
- D. To prevent seizure disorders
Correct Answer: C
Rationale: The primary reason for surgical repair of myelomeningocele is to correct the neurologic defect caused by this type of birth defect. Myelomeningocele is a form of spina bifida where the spinal cord and its covering are exposed through an opening in the spine. Surgical closure of the defect is performed to protect the spinal cord and nerves, prevent further damage, and potentially improve long-term outcomes for the child. While preventing complications like hydrocephalus or infection may be important secondary goals of the treatment, the main objective of surgery for myelomeningocele is to address the underlying neurologic defect itself.
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Which intervention is appropriate for the nurse caring for a client in severe pain receiving a continuous I.V. infusion of morphine?
- A. Assisting with a naloxone challenge test before therapy begins
- B. Discontinuing the drug immediately if signs of dependence appear
- C. Changing the administration route to P.O. if the client can tolerate fluids
- D. Obtaining baseline vital signs before administering the first dose
Correct Answer: D
Rationale: Obtaining baseline vital signs before administering the first dose is appropriate for the nurse caring for a client in severe pain receiving a continuous I.V. infusion of morphine. Monitoring vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, is essential to assess the client's response to opioid therapy. Baseline vital signs provide a comparison for evaluating changes in the client's physical status and help identify any adverse effects or complications related to morphine administration. This proactive approach allows the nurse to detect and address any abnormalities promptly, ensuring the client's safety and optimal pain management.
A client with vaginal cancer asks the nurse, "What is the usual treatment for this type of cancer?" Which treatment should the nurse name?
- A. Surgery
- B. Radiation
- C. Chemotherapy
- D. Immunotherapy
Correct Answer: A
Rationale: The usual treatment for vaginal cancer typically involves surgery. The specific type of surgery can vary depending on the stage and type of cancer, but it often includes removal of the tumor or affected tissue. In some cases, surgery may be combined with other treatments such as radiation or chemotherapy to enhance the effectiveness of the treatment. Surgery is considered a primary treatment option for many cases of vaginal cancer, particularly in early stages where the goal is to remove the cancerous cells and prevent further spread.
The parents of a newborn who has just died decide they want to hold their deceased infant. What is the most appropriate nursing intervention?
- A. Explain gently that this is no longer possible.
- B. Encourage parents to accept the loss of their newborn.
- C. Offer to take a photograph of their newborn because they cannot hold newborn.
- D. Get the newborn, wrap in a blanket, and rewarm in a radiant warmer so parents can hold their deceased infant.
Correct Answer: D
Rationale: The most appropriate nursing intervention in this situation would be to get the newborn, wrap in a blanket, and rewarm in a radiant warmer so parents can hold their deceased infant. This is known as a "cold cuddle" technique, where the infant is gently rewarmed for a short period of time to allow the parents to hold and say goodbye to their baby. This practice has been shown to help parents in the grieving process and is a compassionate way to support them during this difficult time. It allows the parents to have a physical connection with their child and provides them with some closure and the opportunity to create lasting memories.
Why is heart biopsy performed throughout a clients lifetime after heart transplantation?
- A. To detect rejection
- B. To check the heart functionality
- C. To check rate of the heartbeat
- D. To check for heart tumor CARING FOR CLIENTS WITH HYPERTENSION
Correct Answer: A
Rationale: Heart biopsy is performed throughout a client's lifetime after heart transplantation mainly to detect rejection. Rejection is a common complication following a heart transplant where the recipient's immune system recognizes the transplanted heart as foreign tissue and attacks it. By conducting heart biopsies, healthcare providers can monitor the health of the transplanted heart and detect signs of rejection early on. This allows for prompt intervention and adjustment of the client's immunosuppressive therapy to prevent further damage to the transplanted heart. Monitoring for rejection through heart biopsies is crucial in ensuring the long-term success of heart transplants and the overall well-being of the recipient.
Which factor most impacts the type of injury a child is susceptible to, according to the child's age?
- A. Physical health of the child
- B. Developmental level of the child
- C. Educational level of the child
- D. Number of responsible adults in the home
Correct Answer: B
Rationale: The developmental level of the child most impacts the type of injury they are susceptible to based on their age. As children grow and develop, their physical abilities, cognitive skills, and understanding of the environment change. Younger children may be more susceptible to injuries related to exploration and lack of awareness of dangerous situations, while older children may be more prone to injuries during physical activities or sports. Understanding the developmental stage of a child is crucial in assessing potential risks and implementing appropriate safety measures to prevent injuries.