A 2-week-old patient born with a myelomeningocele is to undergo surgical repair of this defect. Which nursing action is of the highest priority in her preoperative care?
Monitoring for apical pulse every hour.
Maintaining the patient in a prone position.
Providing the patient sensory stimulation.
Keeping a strict record of the patient's intake and output.
The Correct Answer is A
Choice A rationale:
Monitoring the apical pulse is of the highest priority for a patient with a myelomeningocele preoperatively. A myelomeningocele is a neural tube defect that can lead to neurologic complications. Monitoring the apical pulse every hour helps detect any signs of cardiac distress or neurological compromise, allowing prompt intervention.
Choice B rationale:
Maintaining the patient in a prone position is not the priority in this situation. While positioning can be important, monitoring vital signs takes precedence over positioning.
Choice C rationale:
Providing sensory stimulation is important for the patient's overall well-being, but it's not the highest priority preoperatively. Monitoring vital signs and assessing for potential complications take precedence.
Choice D rationale:
Keeping a strict record of the patient's intake and output is important for general care, but it's not the highest priority in the immediate preoperative period. Monitoring vital signs and detecting signs of distress come first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Ketonuria is the presence of ketones in urine and is not directly associated with vaso-occlusive crisis in sickle cell anemia. This crisis typically involves pain and ischemia in various body parts.
Choice B rationale:
Diplopia refers to double vision and is not a typical symptom of vaso-occlusive crisis. Pain, not vision changes, is the primary concern in this scenario.
Choice C rationale:
Severe abdominal pain can be a symptom of vaso-occlusive crisis in sickle cell anemia, but the patient's complaint of left elbow pain would not directly correlate with this choice.
Choice D rationale:
Hyperactive patellar reflex is the correct answer. During vaso-occlusive crisis, the body's response to pain can lead to increased muscle tone and reflexes, including hyperactive deep tendon reflexes like the patellar reflex. This is an indicator of neurologic involvement in the crisis. Remember that these rationales are intended to provide a concise understanding of the correct answers based on the information provided in the questions. Always refer to medical literature and consult with healthcare professionals for comprehensive and accurate information.
Correct Answer is B
Explanation
Choice A rationale:
Allowing the patient to stay in the chosen position might not be the best approach, as the child's preference might not align with therapeutic considerations for managing status asthmaticus.
Choice B rationale:
Semi-Fowler's position, with the head of the bed elevated, promotes improved lung expansion and easier breathing for patients with respiratory distress. Explaining the rationale behind this position to the child helps them understand its therapeutic benefits, encouraging compliance.
Choice C rationale:
Demonstrating various positions could confuse the child and delay appropriate intervention. A clear explanation of the preferred position is more effective in this critical situation.
Choice D rationale:
Removing pillows might be counterproductive, as elevating the head of the bed is beneficial for respiratory distress. This choice contradicts the therapeutic goal.
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