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 C

Explanation

Choice A reason: Calling the healthcare provider is important, but the immediate priority is to stop the infusion to prevent further fluid overload, which is likely causing the bilateral crackles.

Choice B reason: Providing supplemental oxygen can be necessary if the child is showing signs of respiratory distress, but it is not the primary action to address the underlying issue of fluid overload.

Choice C reason: Stopping the infusion is the most critical action to prevent further fluid overload, which is causing the bilateral crackles. This immediate intervention can help prevent worsening pulmonary enema and respiratory complications.

Choice D reason: Encouraging oral intake is not appropriate in this scenario as the child is already receiving intravenous fluids for severe dehydration. Additionally, with signs of fluid overload, further fluid intake should be carefully managed.

A. Allow medical staff to make the plan of care decisions. B. Assessing the family's home environment. C. Arranging the necessary care equipment and supplies. D. Referring to financial support.

Correct Answer is A

Explanation

Choice A reason: Allowing medical staff to make the plan of care decisions without involving the patient and their family indicates a lack of patient-cantered care, which is a critical component in effective discharge planning. The patient and family members should be actively involved in the decision-making process to ensure that the plan of care aligns with their needs, preferences, and unique circumstances. Education on the importance of collaboration and shared decision-making in care planning is essential.

Choice B reason: Assessing the family's home environment is a necessary step in discharge planning. This intervention ensures that the patient will have a safe and supportive environment to return to, which can significantly impact their recovery and well-being. It includes evaluating factors such as accessibility, availability of caregivers, and any potential hazards that might affect the patient's health.

Choice C reason: Arranging the necessary care equipment and supplies is an important part of discharge planning to ensure that the patient has all the resources needed to continue their care at home. This includes medical equipment, medications, and other supplies that support the patient's health and recovery. Proper planning and arrangement of these resources prevent gaps in care and promote a smooth transition from hospital to home.

Choice D reason: Referring to financial support is a critical intervention, especially for patients with complex medical histories who may face significant healthcare costs. Financial support can help alleviate the burden of medical expenses and ensure that the patient has access to necessary services and treatments. The nursing student needs to understand the importance of connecting patients with financial resources and support programs.

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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 is caring for a child who is diagnosed with severe dehydration and is being treated with intravenous fluids. The nurse notes bilateral crackles on lung auscultation. Which actions will the nurse prioritize?

Correct Answer is C

Explanation

The nursing student is creating a plan of care for a patient with a complex medical history. Which discharge intervention will require further education by the nursing instructor?

Correct Answer is A

Explanation

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