What is the priority nursing intervention to perform on an infant immediately following repair of a myelomeningocele?
Assess motor function in lower extremities
Maintain skin integrity
Monitor intake and output
Monitor head circumference
The Correct Answer is D
A. Assess motor function in lower extremities: While important for overall neurological assessment, immediate post-repair monitoring of motor function is secondary to monitoring for signs of hydrocephalus (head circumference).
B. Maintain skin integrity: Essential for preventing infection but does not address the immediate post-surgical complication of hydrocephalus.
C. Monitor intake and output: Important for general post-operative care but does not address the immediate concern of monitoring for hydrocephalus.
D. Monitor head circumference: Following repair of a myelomeningocele, infants are at risk for developing hydrocephalus due to abnormal cerebrospinal fluid dynamics. Monitoring head circumference helps detect early signs of increased intracranial pressure, a common complication post-surgery.
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Related Questions
Correct Answer is D
Explanation
A. Use physical restraints during severe outbursts to ensure safety: Restraints should only be used as a last resort and are not an effective or ethical primary strategy for managing behavior in children with ODD.
B. Assign daily chores that are challenging to encourage discipline: Assigning overly challenging chores may lead to frustration and non-compliance, exacerbating behavioral issues rather than helping.
C. Encourage solitary play to reduce social stressors: Isolating the child may worsen feelings of exclusion and does not address the need for social skills development and appropriate behavior in social contexts.
D. Put into practice consistent consequences for rule-breaking behavior: Consistency in consequences helps the child understand boundaries and the importance of following rules, which is crucial for managing behavior in ODD.
Correct Answer is B
Explanation
A. Ensuring that the client takes care of their ADLS to prevent dependence: While promoting independence is important, ensuring safety is a higher priority to prevent immediate harm.
B. Ensuring that the client environment is safe to prevent injury: Safety is the top priority for clients with Alzheimer's due to their increased risk of falls, wandering, and other accidents. A safe environment helps prevent injuries.
C. Ensuring that the client receives food they like to prevent anxiety: Although providing familiar and preferred foods can reduce anxiety, it is not as critical as ensuring a safe environment.
D. Ensuring that the client meets the other patients to prevent social isolation: Social interaction is beneficial, but ensuring safety takes precedence to prevent potential harm.
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