Nokea
Which of the following definition MOST accurately describes meningomyelocele? It is _______.
- A. Spinal cord tumor containing nerve roots.
- B. Complete exposure of the spinal cord and meninges.
- C. Herniation of spinal cord, cerebro-spinal fluid and meninges into a sac.
- D. Sac formation containing meninges and spinal fluid.
Correct Answer: C
Rationale: Meningomyelocele is a type of neural tube defect where there is a protrusion of the spinal cord, cerebrospinal fluid, and meninges through a defect in the vertebrae, forming a sac on the surface of the back. This condition occurs during fetal development when the neural tube fails to close completely, leading to the exposure of the spinal cord and its coverings. This herniation can result in a range of neurological deficits and complications, requiring surgical repair shortly after birth to prevent further damage and infections.
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Ms. C is at risk for refeeding syndrome that is caused by rapid feeding. What should be the priority action of the health care team to prevent complications associated with this syndrome?
- A. Assess for signs of pallor of the extremities and sluggish capillary refill
- B. Monitor for decreased bowel sounds, nausea, bloating, and abdominal distention
- C. Observe for signs of secret purging and ingestion of water to increase weight
- D. Monitor for peripheral edema, crackles in the lungs, and jugular vein distention
Correct Answer: B
Rationale: Refeeding syndrome is a potentially dangerous condition that can occur in malnourished individuals when nutrition is reintroduced too quickly. It is characterized by shifts in electrolytes, fluid imbalance, and metabolic abnormalities. Monitoring for decreased bowel sounds, nausea, bloating, and abdominal distention is the priority action to prevent complications associated with refeeding syndrome. These symptoms can indicate gastrointestinal issues such as ileus or overfeeding, which can lead to further complications. Early recognition and intervention can help prevent serious consequences of refeeding syndrome.
The nurse did an admission procedure. The best position to be assumed by Roy is _____.
- A. left lateral position with the affected side inferior.
- B. semi-fowler position at least 30 degrees.
- C. dorsal position with pillows under the chest.
- D. lying on his side, the affected side of the lungs should be superior.
Correct Answer: B
Rationale: The best position for a patient to assume during an admission procedure, particularly for respiratory assessment, is the semi-fowler position at least 30 degrees. In the semi-fowler position, the patient's head and upper body are elevated to a 30-degree angle. This position helps improve lung expansion and oxygenation by reducing pressure on the diaphragm and enhancing chest expansion. It also facilitates breathing and allows for better assessment of respiratory status. Additionally, the semi-fowler position helps prevent aspiration and promotes comfort and relaxation for the patient during the admission procedure.
A postpartum client presents with persistent, severe abdominal pain, distention, and absent bowel sounds. Which nursing action is most appropriate?
- A. Encouraging the client to ambulate to promote bowel function
- B. Providing a heating pad to alleviate abdominal discomfort
- C. Notifying the healthcare provider immediately
- D. Administering a laxative to promote bowel evacuation
Correct Answer: C
Rationale: The most appropriate nursing action in this situation is to notify the healthcare provider immediately. The symptoms the postpartum client is experiencing - persistent, severe abdominal pain, distention, and absent bowel sounds - are concerning and could indicate a serious underlying issue such as bowel obstruction or other complications. Prompt communication with the healthcare provider is crucial to ensure the client receives the necessary assessment, intervention, and treatment. Encouraging ambulation, providing a heating pad, or administering a laxative are not appropriate actions in this case without first consulting with the healthcare provider due to the severity and potential complexity of the client's symptoms.
A patient expresses frustration with the treatment plan proposed by the healthcare team. What is the most appropriate response from the nurse?
- A. Dismiss the patient's concerns and assure them that the treatment plan is the best option.
- B. Empathize with the patient's frustration and explore their concerns further.
- C. Ignore the patient's frustration and proceed with implementing the treatment plan.
- D. Tell the patient that they have no choice but to follow the treatment plan.
Correct Answer: B
Rationale: The most appropriate response from the nurse when a patient expresses frustration with the treatment plan proposed by the healthcare team is to empathize with the patient's frustration and explore their concerns further. It is important to actively listen to the patient, acknowledge their feelings, and address any questions or uncertainties they may have about the treatment plan. By engaging in open communication and demonstrating empathy, the nurse can foster a therapeutic relationship with the patient and work towards finding a solution that is mutually agreeable and beneficial for the patient's well-being. Dismissing the patient's concerns (Option A) or ignoring their frustration (Option C) can lead to a breakdown in communication and trust, which may ultimately impact the patient's compliance with the treatment plan. Similarly, telling the patient that they have no choice but to follow the treatment plan (Option D) can be perceived as dismissive and confrontational, which is not conducive to promoting patient-centered care.
A woman in active labor experiences persistent fetal malposition, with the fetus in a transverse lie presentation. What nursing intervention should be prioritized to address this abnormal labor presentation?
- A. Facilitating external cephalic version (ECV)
- B. Assisting the mother into a hands-and-knees position
- C. Preparing for immediate instrumental delivery
- D. Initiating continuous electronic fetal monitoring
Correct Answer: B
Rationale: When a woman in active labor experiences persistent fetal malposition, such as a transverse lie presentation, assisting the mother into a hands-and-knees position is a nursing intervention to prioritize. This position can help encourage the fetus to rotate into a more favorable position for delivery, such as a head-down position. By placing the mother in a hands-and-knees position, gravity can assist in shifting the fetus to the correct position. This intervention is non-invasive and can be effective in promoting the progress of labor and avoiding the need for more invasive interventions like instrumental delivery or cesarean section. However, if the fetus does not rotate or if there are signs of fetal distress, further interventions may be necessary.