Nokea
The nurse is caring for a family whose infant was just born with anencephaly. What is the most important nursing intervention?
- A. Implement measures to facilitate the attachment process.
- B. Help the family cope with the birth of an infant with a fatal defect.
- C. Prepare the family for extensive surgical procedures that will be needed.
- D. Provide emotional support so the family can adjust to the birth of an infant with problems.
Correct Answer: B
Rationale: Anencephaly, a fatal neural tube defect, requires nursing support to help families cope with grief and provide comfort measures for the infant, who may survive briefly. Attachment is encouraged but secondary, no surgical options exist, and general support is less specific.
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A 14-year-old girl is in the intensive care unit after a spinal cord injury 2 days ago. What nursing intervention is a priority for this child?
- A. Minimizing environmental stimuli
- B. Administering immunoglobulin
- C. Monitoring and maintaining systemic blood pressure
- D. Discussing long-term care issues with the family
Correct Answer: C
Rationale: Monitoring and maintaining blood pressure is critical in spinal cord injury due to physiologic lability and risks like autonomic dysreflexia. Stimuli minimization and immunoglobulin aren?t needed, and long-term care discussions are premature during acute stabilization.
An 8-year-old child is hospitalized with infectious polyneuritis (Guillain-Barré syndrome [GBS]). When explaining this disease process to the parents, what should the nurse consider?
- A. Paralysis is progressive with little hope for recovery.
- B. Disease is inherited as an autosomal, sex-linked, recessive gene.
- C. Disease results from an apparently toxic reaction to certain medications.
- D. Muscle strength slowly returns, and most children recover.
Correct Answer: D
Rationale: GBS involves progressive paralysis with recovery of muscle strength starting within 2-3 weeks, with most children regaining full strength, especially younger ones. It?s immune-mediated, not inherited or medication-induced, and has a good prognosis.
What type of cerebral palsy (CP) is the most common type?
- A. Ataxic
- B. Spastic
- C. Dyskinetic
- D. Mixed type
Correct Answer: B
Rationale: Spastic CP, marked by initial hypotonia transitioning to hypertonicity, is the most common type. Ataxic, dyskinetic, and mixed types are less frequent, with spastic CP showing increased stretch reflexes and weakness.
During a well-child visit, the mother tells the nurse that her 4-month-old infant is constipated, is less active than usual, and has a weak-sounding cry. The nurse suspects botulism and questions the mother about the childs diet. What factor should support this diagnosis?
- A. Breastfeeding
- B. Commercial formula
- C. Infant cereal with honey
- D. Improperly sterilized bottles
Correct Answer: C
Rationale: Honey ingestion is a known risk factor for infant botulism in children under 1 year, supporting the diagnosis given symptoms like constipation and weakness. Breastfeeding and formula have minimal risk, and bottle sterilization issues are unrelated to botulism.
What statement is most accurate in describing tetanus?
- A. Inflammatory disease that causes extreme, localized muscle spasm.
- B. Disease affecting the salivary gland with resultant stiffness of the jaw.
- C. Acute infectious disease caused by an exotoxin produced by an anaerobic spore-forming, gram-positive bacillus.
- D. Acute infection that causes meningeal inflammation resulting in symptoms of generalized muscle spasm.
Correct Answer: C
Rationale: Tetanus, caused by Clostridium tetani?s exotoxins, affects the central nervous system, causing muscle stiffness and spasms, starting with the jaw (lockjaw). It?s not inflammatory, doesn?t affect salivary glands, and isn?t caused by meningeal inflammation.