The nurse is caring for a 14-year-old patient following myelography. What is the priority nursing action?

Observing for mental confusion or hallucinations.

Assessing motor function.

Monitoring for a decrease in spasticity.

Performing a follow-up MRI.

Answer and Explanation

The Correct Answer is C

Choice A reason: Observing for mental confusion or hallucinations is important, but it is not the priority action following myelography. While these symptoms can occur due to complications, they are less common than changes in muscle tone or motor function.

Choice B reason: Assessing motor function is crucial, but the priority is specifically monitoring for changes in muscle tone, such as a decrease in spasticity. Myelography can affect the spinal cord and nerve roots, potentially leading to changes in muscle tone and motor function.

Choice C reason: Monitoring for a decrease in spasticity is the priority nursing action. Myelography involves injecting contrast material into the spinal canal, which can affect the spinal cord and nerve roots. Monitoring for changes in muscle tone, such as a decrease in spasticity, helps detect potential complications early and allows for timely intervention.

Choice D reason: Performing a follow-up MRI is not the immediate priority nursing action. While follow-up imaging may be necessary to assess the results of the myelography, the immediate focus is on monitoring the patient's neurological status and ensuring their safety.

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Correct Answer is B

Explanation

Choice A reason: Cheese sauce may be high in fat and sodium, but noodles with cheese sauce are generally safe for an 11-month-old infant to consume in moderation. The primary concern for infants' diet is ensuring that foods are safe to swallow and do not pose a choking hazard, which noodles do not.

Choice B reason: Honey is not recommended for children under one year old due to the risk of botulism, a serious illness caused by a toxin produced by the bacterium Clostridium botulinum. Infants have underdeveloped immune systems that cannot fight off the toxin, making honey a potentially dangerous food choice for them.

Choice C reason: Cooked broccoli is generally a safe and nutritious food for an 11-month-old infant. It's a good source of vitamins, minerals, and fibre. However, it should be soft enough for the infant to chew and swallow without risk of choking.

Choice D reason: Cut-up cherry tomatoes are appropriate for an 11-month-old infant as long as they are cut into small, manageable pieces to prevent choking. Cherry tomatoes provide essential nutrients like vitamins A and C and can be a healthy addition to an infant's diet.

A. Facilitate an early discharge. B. Discontinue oxycodone administration. C. Restrict visitor time. D. Provide breast pump.

Correct Answer is ["B","C","D"]

Explanation

Choice A reason: Facilitating an early discharge is not appropriate in this case. Patients with PPROM require careful monitoring and management to prevent infections and other complications.

Choice B reason: Discontinuing oxycodone administration may be necessary to prevent potential adverse effects on both the patient and the baby, especially considering the patient's recent delivery and current condition.

Choice C reason: Restricting visitor time can help reduce the risk of infection, especially for a patient with PPROM and a newborn who may have a compromised immune system.

Choice D reason: Providing a breast pump is important to help the mother establish and maintain lactation, especially if the baby is premature and may have difficulty breastfeeding directly.

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The nurse is caring for a 14-year-old patient following myelography. What is the priority nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse case manager is conducting a home visit for a family with an 11-month-old infant. When reviewing the infant's dietary intake, which food choice by the family requires further education by the nurse?

Correct Answer is B

Explanation

The nurse is caring for a G4P1, 31 weeks and 2 days gestation, 41-year-old patient, with premature prolonged rupture of membranes (PPROM) 7 hours after delivery. Which interventions will the nurse include in the plan of care? Select all that apply.

Correct Answer is ["B","C","D"]

Explanation

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