A nurse is creating a plan of care for an adolescent who has muscular dystrophy. Which of the following interventions should the nurse include in the plan?
Recommend the adolescent use a wheelchair to prevent stress on the lower extremities.
Avoid influenza and pneumococcal vaccines for 24 months.
Initiate a referral for chest physiotherapy every 4 hours.
Encourage the adolescent to perform incentive spirometry to maintain lung capacity.
Correct Answer : A,C,D
Choice A reason: Recommending the use of a wheelchair can help prevent stress on the lower extremities, which is important for an adolescent with muscular dystrophy. This condition can lead to muscle weakness and using a wheelchair can aid in mobility and independence.
Choice B reason: Avoiding influenza and pneumococcal vaccines is not recommended. Vaccinations are important for preventing infections, especially in individuals with compromised health conditions like muscular dystrophy.
Choice C reason: Initiating a referral for chest physiotherapy every 4 hours can be beneficial for an adolescent with muscular dystrophy. This therapy can help clear mucus from the lungs and improve respiratory function, which is often compromised in this condition.
Choice D reason: Encouraging the adolescent to perform incentive spirometry is important to maintain lung capacity. Muscular dystrophy can affect the muscles used for breathing, and incentive spirometry can help strengthen these muscles and improve respiratory health.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Applying tepid water to the old dressings can help with their removal and may reduce discomfort, but it does not address the greatest risk to the client, which is infection.
Choice B reason: Checking the wound sites for manifestations of infection is crucial as burn injuries compromise the skin's protective barrier, making the client highly susceptible to infections. Infections can lead to further complications and delay healing.
Choice C reason: Performing passive range-of-motion exercises is important for maintaining joint mobility and preventing contractures in burn patients, but it is not the primary intervention for addressing the greatest risk of infection.
Choice D reason: Adjusting the room temperature to 33°C (91.4°F) can create a more comfortable environment for the burn patient and prevent hypothermia, but it is not directly related to the prevention of infection, which is the greatest risk.
Correct Answer is D
Explanation
Choice Areason: An upper respiratory infection 2 days ago, if the child is currently well, is not a contraindication for the MMR vaccine. Vaccines can be given to children with a minor illness.
Choice Breason: A temperature of 37.2° C (99°F) is a mild elevation and is not a contraindication for receiving the MMR vaccine. Vaccination can proceed if the child is only mildly ill.
Choice C reason: A family history of seizures is not a contraindication for the MMR vaccine. While there is a small risk of febrile seizures, the benefits of vaccination outweigh the risks.
Choice D reason: An allergy to neomycin is a contraindication for the MMR vaccine because neomycin is used in the vaccine production process. Children with a known severe allergic reaction to neomycin should not receive the vaccine.
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