A nurse is orienting a newly licensed nurse in caring for an infant with myelomeningocele. Which of the following actions by the new nurse indicates the teaching has been effective?
Takes an axillary temperature.
Performs range of motion on the infant's hips.
Places the infant in a side-lying position.
Maintains a dry dressing over the sac.
The Correct Answer is D
Choice A reason: Taking an axillary temperature is standard but not specific to myelomeningocele care. While monitoring for infection is important, it does not address the unique need to protect the exposed spinal sac, which is critical to prevent infection and trauma in this condition.
Choice B reason: Performing range of motion on the hips risks damaging the myelomeningocele sac, which contains nerve roots. Movement could cause sac rupture or neurological worsening, as the exposed neural tissue is highly vulnerable, making this action contraindicated in this fragile condition.
Choice C reason: Side-lying positioning may be used but is not the most critical action. It helps avoid pressure on the sac, but maintaining a dry, sterile dressing is paramount to prevent infection, a life-threatening complication in myelomeningocele due to exposed neural tissue.
Choice D reason: Maintaining a dry dressing over the myelomeningocele sac prevents infection and trauma to exposed neural tissue. A sterile, moist environment protects the sac until surgical repair, reducing the risk of meningitis or further neurological damage, indicating effective understanding of this condition’s care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Bradycardia is not associated with Graves' disease, which causes hyperthyroidism, increasing metabolic rate and heart rate. Excess thyroid hormone accelerates cardiac activity, leading to tachycardia, not slowed heart rate, making this an incorrect finding for an exacerbation of this condition.
Choice B reason: Weight gain is unlikely in Graves' disease, as hyperthyroidism increases metabolism, causing weight loss despite increased appetite. Excess thyroid hormone accelerates caloric expenditure, leading to fat and muscle breakdown, making weight gain atypical during an exacerbation of this condition.
Choice C reason: Heat intolerance is a hallmark of Graves' disease due to hyperthyroidism increasing metabolic rate, generating excess body heat. The sympathetic nervous system is overstimulated, impairing heat dissipation, causing sweating and discomfort in warm environments, a common symptom during disease exacerbation.
Choice D reason: Lethargy is not typical in Graves' disease, as hyperthyroidism causes increased energy, restlessness, and insomnia due to elevated metabolism. Fatigue may occur from sustained hyperactivity, but lethargy is more associated with hypothyroidism, making this an incorrect finding for this condition.
Correct Answer is A
Explanation
Choice A reason: The Glasgow Coma Scale assesses cognitive status by evaluating eye-opening, verbal, and motor responses. It quantifies consciousness level after a head injury, detecting neurological impairment due to trauma. This non-invasive tool provides immediate data on brain function, guiding further diagnostic and treatment decisions.
Choice B reason: A CT scan identifies structural brain injuries, like hematomas, but does not directly assess cognitive function. It visualizes anatomical damage rather than real-time neurological status, making it secondary to tools like the Glasgow Coma Scale for immediate cognitive assessment post-injury.
Choice C reason: Blood work can detect metabolic or infectious causes of altered cognition but does not directly evaluate cognitive status. It may reveal secondary issues like hypoglycemia but lacks specificity for assessing brain function after a head injury, making it less relevant for this purpose.
Choice D reason: Monitoring intracranial pressure is critical in severe head injuries but requires invasive devices and does not directly assess cognitive status. It measures pressure dynamics, not consciousness or cognitive function, making it inappropriate for initial cognitive evaluation compared to the Glasgow Coma Scale.
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