The nurse is planning care for a child with muscular dystrophy.
What is an appropriate nursing goal?
Cure the disease.
Prevent injury.
Promote rapid ambulation.
Reverse muscle weakness.
The Correct Answer is B
Choice A rationale
Muscular dystrophy is a progressive, incurable genetic disorder characterized by muscle degeneration and weakness. While supportive care can manage symptoms and complications, there is currently no known cure. Therefore, setting a goal to cure the disease is unrealistic and inappropriate in the nursing care plan.
Choice B rationale
Children with muscular dystrophy experience progressive muscle weakness, increasing their risk of falls, fractures, and respiratory complications. A primary nursing goal is to prevent injury by implementing strategies such as maintaining mobility within limits, providing assistive devices, ensuring a safe environment, and monitoring for complications.
Choice C rationale
Muscular dystrophy leads to progressive muscle weakness, making rapid ambulation increasingly difficult and eventually impossible. Promoting rapid ambulation as a goal is counterproductive and unrealistic, as it does not align with the progressive nature of the disease and could lead to injury. The focus shifts to maintaining mobility for as long as possible.
Choice D rationale
Reversing muscle weakness in muscular dystrophy is not possible because the disease involves the degeneration of muscle fibers due to genetic defects. Nursing interventions focus on managing symptoms, slowing progression, and maintaining function, but they cannot reverse the underlying pathological process of muscle fiber loss and replacement with connective tissue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Vitamin K's primary physiological role is in coagulation, not in enhancing the immune system to prevent healthcare-associated infections. Newborns receive vitamin K to prevent bleeding disorders, not to boost their immunity against bacterial or viral pathogens. Infection control practices are crucial for preventing healthcare-associated infections, not vitamin K administration.
Choice B rationale
Vitamin K is essential for the synthesis of clotting factors II, VII, IX, and X in the liver. Newborns have immature livers and limited vitamin K stores, making them susceptible to Vitamin K Deficiency Bleeding (VKDB), also known as hemorrhagic disease of the newborn. Administering vitamin K prophylactically decreases this risk, preventing potentially life-threatening bleeding episodes.
Choice C rationale
Vitamin K is administered to prevent hemorrhagic disorders and has no known direct impact on reducing complications specifically from the Hepatitis B vaccine. The Hepatitis B vaccine stimulates active immunity against the Hepatitis B virus. Any complications from vaccination are unrelated to the infant's vitamin K status or coagulation cascade.
Choice D rationale
Jaundice in newborns is primarily caused by elevated unconjugated bilirubin levels due to physiological processes like increased red blood cell breakdown and immature liver conjugation. Vitamin K does not play a role in bilirubin metabolism or excretion, and therefore, it does not decrease the newborn's risk of jaundice. Phototherapy or other interventions are used for hyperbilirubinemia.
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale
Contractions that increase in intensity are a hallmark of true labor. In true labor, uterine contractions become stronger, more regular, and longer in duration due to increasing myometrial activity and prostaglandin release, which contribute to cervical effacement and dilation. This differs from Braxton Hicks contractions, which typically remain mild.
Choice B rationale
Leakage of fluid from the vagina, often referred to as rupture of membranes, signifies the spontaneous breaking of the amniotic sac. This event can occur before or during true labor and increases the risk of infection and cord prolapse. It is a definitive sign that the labor process has begun or is imminent.
Choice C rationale
Increased bladder pressure is a common discomfort experienced by pregnant clients due to the growing uterus compressing the bladder. However, it is not a specific indicator of true labor. It can occur throughout the third trimester as the fetal head descends into the pelvis, regardless of labor onset.
Choice D rationale
Blood-tinged vaginal mucus, also known as "bloody show," results from the softening and effacement of the cervix, causing capillaries to rupture and release a small amount of blood mixed with mucus. This is a common sign indicating that the cervix is undergoing changes in preparation for labor.
Choice E rationale
Uterine contractions that decrease with rest are characteristic of Braxton Hicks contractions, or "false labor.”. True labor contractions, in contrast, persist and often intensify with activity and do not diminish with rest or changes in position, reflecting progressive physiological changes of labor.
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