Which is the priority nursing intervention for an infant diagnosed with myelomeningocele?
Educating caregivers on sensory impairment.
Preventing infection.
Correction of joint contractures.
Measuring daily head circumference.
The Correct Answer is B
Choice A rationale:
While educating caregivers on sensory impairment is important for an infant with myelomeningocele, preventing infection takes precedence as the priority nursing intervention.
Choice B rationale:
The correct answer. Preventing infection at the site of the myelomeningocele is crucial to avoid potentially life-threatening complications, such as meningitis. The exposed neural tissue poses a significant infection risk.
Choice C rationale:
Correcting joint contractures is important but is a secondary concern compared to preventing infection, which can have more immediate and severe consequences.
Choice D rationale:
Measuring daily head circumference is important to monitor for hydrocephalus in these infants, but preventing infection remains the higher priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Stomatitis, inflammation of the oral mucosa, can make eating painful, leading to inadequate nutritional intake. The discomfort caused by stomatitis can discourage the patient from eating, potentially resulting in malnutrition. Ensuring adequate nutritional intake is crucial to support the patient's immune system and healing during antineoplastic therapy.
Choice B rationale:
Dental caries are not directly related to stomatitis. Stomatitis is inflammation of the oral mucosa, whereas dental caries involve decay of tooth structure due to bacterial action on food debris and sugars.
Choice C rationale:
Diarrhea is unrelated to stomatitis. Diarrhea involves frequent, loose, or watery stools, often caused by gastrointestinal infections, certain medications, or dietary intolerances.
Choice D rationale:
Gingival hyperplasia is an overgrowth of gum tissue and is not a likely result of stomatitis. It can be associated with some medications like anticonvulsants.
Correct Answer is D
Explanation
Choice A rationale:
The patient ties his shoelaces. This choice is incorrect as most 3-year-olds lack the fine motor skills required to tie shoelaces independently.
Choice B rationale:
The patient gives his first and last name. This choice is also incorrect, as most 3-year-olds might not have developed language skills to provide their full name accurately.
Choice C rationale:
The patient can tell time. This choice is unrealistic for a 3-year-old, as telling time involves cognitive and conceptual abilities that are not yet developed at this age.
Choice D rationale:
The patient draws a stick figure with six parts. This choice is correct. Around age 3, children usually start drawing simple figures with a head, arms, legs, and possibly facial features, totaling around six parts. This reflects appropriate developmental milestones for a child of this age.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today