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 A
Explanation
Choice A rationale
According to Erik Erikson's theory of psychosocial development, adolescence (roughly ages 12-18) is characterized by the central crisis of identity versus role confusion. During this stage, adolescents explore various roles, beliefs, and values to form a cohesive sense of self and define their place in society, integrating past experiences with future aspirations.
Choice B rationale
Autonomy versus shame and doubt is the psychosocial crisis associated with early childhood, typically ages 1-3 years. During this stage, children develop a sense of personal control over physical skills and a sense of independence. Successful resolution leads to autonomy, while failure can result in feelings of shame and self-doubt.
Choice C rationale
Trust versus mistrust is the psychosocial crisis of infancy, typically ages 0-1 year. In this stage, infants develop a sense of trust in caregivers and the world based on the consistency and reliability of care received. Successful resolution fosters hope and security, while neglect can lead to mistrust and anxiety.
Choice D rationale
Industry versus inferiority is the psychosocial crisis characteristic of school age, typically ages 6-12 years. Children at this stage are focused on developing competence and mastering academic and social skills. Success in these endeavors leads to a sense of industry, while difficulties can result in feelings of inferiority and low self-esteem.
Correct Answer is C
Explanation
Choice A rationale
Providing a high-protein diet is beneficial for tissue repair and overall healing, as proteins are essential building blocks for cells and enzymes involved in the inflammatory and reparative processes. However, this intervention is secondary to addressing the underlying infection. Nutritional support optimizes recovery but does not directly eliminate the bacterial pathogen.
Choice B rationale
Encouraging weight-bearing on the affected limb is contraindicated in acute osteomyelitis. This action could exacerbate inflammation, increase pain, and potentially lead to pathological fractures or further dissemination of the infection within the bone, compromising structural integrity and delaying healing. Rest is crucial for minimizing stress on the compromised bone.
Choice C rationale
Administering IV antibiotics as prescribed is the priority intervention because osteomyelitis is a severe bacterial infection of the bone. Intravenous administration ensures high systemic concentrations of antibiotics, reaching the infected bone tissue efficiently to eradicate the pathogen, prevent further bone destruction, and reduce the risk of systemic complications like sepsis.
Choice D rationale
Applying heat packs to the affected area might provide some symptomatic relief from pain by increasing blood flow, but it is not a primary intervention for osteomyelitis. Heat can potentially increase swelling and may not be effective in reaching the deep-seated infection within the bone. Direct antimicrobial therapy is paramount for resolution.
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