A nurse is assessing a child who has been diagnosed with muscular dystrophy. Which of the following assessment findings should the nurse expect? (Select All that Apply.)
Delayed motor development
Lung defects
Scoliosis
Insomnia
Muscle weakness
Correct Answer : A,B,C,E
A. Delayed motor development: Muscular dystrophy is characterized by progressive muscle degeneration that often presents in early childhood. Delayed milestones such as late walking, difficulty running, or frequent falls are common early assessment findings.
B. Lung defects: Progressive weakness of respiratory muscles can impair ventilation and cough effectiveness. Over time, this can lead to restrictive lung disease, recurrent respiratory infections, and decreased pulmonary function.
C. Scoliosis: Weakness of trunk and paraspinal muscles contributes to abnormal spinal curvature. As muscle imbalance progresses, scoliosis commonly develops and can further compromise respiratory function.
D. Insomnia: Sleep disturbances are not a defining or expected manifestation of muscular dystrophy. While fatigue may occur, insomnia is not a characteristic assessment finding related to the disease process itself.
E. Muscle weakness: Progressive, symmetrical muscle weakness is the hallmark feature of muscular dystrophy. It typically begins in proximal muscles and worsens over time, significantly affecting mobility and functional ability.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
A. Fixation on certain items or topics: Children with ASD often develop intense interests or focus on specific objects or topics, which is a characteristic behavior and should be included in parental education.
B. Frequent changes in routine: Children with ASD typically struggle with changes in routine and may become distressed when routines are disrupted, so frequent changes are not characteristic and should not be encouraged.
C. Display of self-harming behaviors such as head-banging: Some children with ASD may engage in self-injurious behaviors, including head-banging or biting, particularly during times of frustration or sensory overload.
D. Spontaneous and unpredictable behaviors: Behaviors in ASD are usually repetitive or predictable rather than spontaneous; unpredictability is not a defining characteristic.
E. Adhering to a rigid routine: A strong preference for sameness and strict adherence to routines is common in children with ASD and should be recognized by caregivers.
F. Avoidance of repetitive activities: Children with ASD typically engage in repetitive behaviors such as hand-flapping, rocking, or repeating words, so avoidance of these is not typical.
Correct Answer is A
Explanation
A. The tumor originated in the adrenal glands: Neuroblastoma is a malignancy of the sympathetic nervous system, most commonly arising in the adrenal medulla. It can also develop along the sympathetic chain in the neck, chest, or abdomen. Adrenal origin accounts for approximately 40% of cases in children.
B. The tumor has not spread to other areas of the child's body: Neuroblastoma is often metastatic at diagnosis, commonly spreading to bones, bone marrow, lymph nodes, liver, and skin. Localized tumors are less common, and assuming no spread is inaccurate.
C. The tumor came from malformation of astrocyte glial brain cells: Tumors of astrocytes are classified as astrocytomas or gliomas, which are primary brain tumors. Neuroblastoma arises from neural crest cells, not glial cells.
D. The tumor is located in the lower back of the brain in the midline posterior fossa: This description is characteristic of medulloblastoma, a central nervous system tumor. Neuroblastoma originates in peripheral sympathetic tissue, not the posterior fossa of the brain.
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