Nokea
If the parents of a child with Duchenne's muscular dystrophy are having a difficult time accepting the diagnosis, which nursing action is most beneficial to the family?
- A. Recommend that the parents place the child in an institution.
- B. Recommend that the parents contact the local social welfare agency.
- C. Recommend that the parents talk with other parents who have children with muscular dystrophy.
- D. Recommend that the parents read as much literature as possible about treatment of muscular dystrophy.
Correct Answer: C
Rationale: Connecting with other parents who have children with Duchenne's muscular dystrophy provides emotional support and practical insights, helping the family cope with the diagnosis.
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Which of the following statements made by the adolescent best supports the nurse's suspicion of scoliosis?
- A. My friends are getting taller faster than I am.
- B. One of my sleeves is always shorter than the other.
- C. I have a difficult time sleeping on my side at night.
- D. I have a difficult time sleeping on my side at night.
Correct Answer: B
Rationale: Uneven sleeve length suggests shoulder asymmetry, a common sign of scoliosis due to lateral spinal curvature affecting posture.
If the nurse documents all the following data, which finding should be reported immediately?
- A. Refusal to eat
- B. Complaint of nausea
- C. Absent bowel sounds
- D. Temperature of 101°F (38.3°C) orally
Correct Answer: C
Rationale: Absent bowel sounds may indicate peritonitis or bowel obstruction, serious complications of appendicitis requiring immediate reporting to prevent further deterioration.
Total bishops score is:
- A. 10
- B. 8
- C. 6
- D. 4
- E. 13
Correct Answer: E
Rationale: The Bishop score assesses cervical readiness for labor with a maximum of 13 points (dilation effacement station consistency position). Higher scores indicate better inducibility.
The common possible cause of oligohydramnios is:
- A. Oesophageal atresia.
- B. Placental haemangioma.
- C. Renal agenesis.
- D. Diabetes mellitus.
- E. Rh incompatibility.
Correct Answer: C
Rationale: Renal agenesis leads to oligohydramnios because the fetus cannot produce urine a major component of amniotic fluid. Other options are less commonly associated with reduced amniotic fluid.
The nurse is assessing the infant who may have FAS. Which findings,if observed,should the nurse associate with FAS? Select all that apply.
- A. Broad nasal bridge and flat midface
- B. Growth deficit in weight and length
- C. Excessive irritability and hypotonia
- D. Poor feeding and persistent vomiting
- E. Large jaw and overdeveloped maxilla
Correct Answer: A,B,C,D
Rationale: FAS features include broad nasal bridge flat midface growth deficits irritability hypotonia and poor feeding/vomiting due to alcohol’s effects. The jaw is small not large.