A 9-month-old with Tay-Sachs disease is admitted due to seizures. Which assessment is most important for the nurse to obtain?
Ability to crawl.
Eyes with cherry-red spot.
Difficulty with swallowing.
Exaggerated startle reaction
The Correct Answer is D
Choice A reason: The ability to crawl is not the most important assessment for the nurse to obtain. Tay-Sachs disease causes progressive loss of motor skills, so the infant may not be able to crawl or may have regressed from crawling. However, this is not a specific sign of the disease and does not indicate the severity of the condition.
Choice B reason: The eyes with cherry-red spot are not the most important assessment for the nurse to obtain. Tay-Sachs disease causes accumulation of gangliosides in the retina, which results in a cherry-red spot in the center of the macula. However, this is not a specific sign of the disease and does not indicate the severity of the condition.
Choice C reason: The difficulty with swallowing is not the most important assessment for the nurse to obtain. Tay-Sachs disease causes muscle weakness and spasticity, which may affect the infant's ability to swallow. However, this is not a specific sign of the disease and does not indicate the severity of the condition.
Choice D reason: The exaggerated startle reaction is the most important assessment for the nurse to obtain. Tay-Sachs disease causes increased sensitivity to sound and touch, which results in an exaggerated startle reaction. This is a specific sign of the disease and indicates the severity of the condition. The exaggerated startle reaction may also trigger seizures, which can be life-threatening. The nurse should monitor the infant's vital signs, seizure activity, and neurological status closely.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Enalapril is an angiotensin-converting enzyme (ACE) inhibitor that is used to treat heart failure in infants. It lowers blood pressure and reduces the workload of the heart. Enalapril is not contraindicated in this scenario and does not need to be withheld.
Choice B reason: Digoxin is a cardiac glycoside that is used to treat heart failure and arrhythmias in infants. It increases the contractility of the heart and slows down the heart rate. Digoxin has a narrow therapeutic range and can cause toxicity if the dose is too high or the infant is dehydrated. Digoxin should be withheld if the infant's apical pulse is less than 90 beats/minute, which is the case in this scenario. The nurse should notify the health care provider and monitor the infant for signs of digoxin toxicity, such as nausea, vomiting, bradycardia, and visual disturbances.
Choice C reason: Hydralazine is a vasodilator that is used to treat hypertension and heart failure in infants. It lowers blood pressure and reduces the afterload of the heart. Hydralazine is not contraindicated in this scenario and does not need to be withheld.
Choice D reason: Furosemide is a loop diuretic that is used to treat fluid overload and edema in infants with heart failure. It lowers blood pressure and reduces the preload of the heart. Furosemide is not contraindicated in this scenario and does not need to be withheld
Correct Answer is A
Explanation
Choice A reason: Asking the boy to describe a typical day at school is the best intervention that the nurse can implement. This can help the nurse identify any possible sources of stress or anxiety that may be causing the boy's physical symptoms. The nurse can also provide emotional support and guidance to the boy and his parents on how to cope with the school-related challenges.
Choice B reason: Conducting a complete neurological assessment is not the best intervention that the nurse can implement. This is not necessary unless the boy has other signs of neurological problems, such as seizures, vision changes, or altered mental status. A neurological assessment may also be invasive and uncomfortable for the boy and may increase his anxiety.
Choice C reason: Counseling the parents to pay more attention to the child is not the best intervention that the nurse can implement. This may imply that the parents are neglectful or irresponsible, which may not be true. The nurse should avoid making assumptions or judgments about the parents' behavior and instead collaborate with them to find the best solutions for the child's well-being.
Choice D reason: Comparing the child's vital signs over the past three weeks is not the best intervention that the nurse can implement. This may not provide much useful information, as the child's vital signs may vary depending on the time of day, activity level, and emotional state. The nurse should focus more on the child's subjective complaints and psychosocial factors.
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