Intracranial/mobility/hormonal

1. The nurse is developing a plan of care for a child recently diagnosed with cerebral palsy (CP). Which intervention is the priority?

• 1. Ensure the child learns to walk and talk

• Teach the caregiver strategies to care for the child.

• 1. Create a diet plan so the child has sufficient calories for growth.

• Discuss the need for a PEG tube.

Answer explanation

Teaching appropriate caregiving strategies for a special-needs child is important and is done so that the child can maximize personal skills and minimize limitations. 

The nurse is caring for a client with bacterial meningitis. What assessment findings would the nurse expect?

Select all that apply

• 102.3 degrees F

• photophobia

• positive kernig

• negative bradinski

• Heart rate 89

2. A nurse is providing education to a group of caregivers about Duchenne muscular dystrophy (DMD). Which statement by a caregiver indicates a need for further teaching?

• 1. “DMD primarily affects males due to its inheritance pattern.”

• "Early diagnosis and intervention can help improve muscle function in DMD."

• 1. "Physical therapy and exercise are not recommended for children with DMD."

• 1. "Genetic testing can confirm the presence of dystrophin gene mutations in DMD."

Answer explanation

Physical therapy and exercise are recommended for children with Duchenne muscular dystrophy (DMD). While DMD is a progressive disorder that leads to muscle degeneration, early intervention with physical therapy and targeted exercises can help maintain muscle function, improve mobility, and delay the progression of muscle weakness. DMD primarily affects males due to its X-linked inheritance pattern. Early diagnosis and intervention, including physical therapy and other supportive measures, can help improve muscle function and quality of life in children with DMD. Genetic testing is used to confirm the presence of dystrophin gene mutations, which is a key diagnostic marker for DMD.

The nurse is planning the care of a client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Which interventions should be implemented? Select all that apply

• Assess level of consciousness

• Restrict fluids per health-care provider order

• Daily weights

• Place patient on seizure precautions

• 
  IV NS infusion to run at 75 ml/hr

Answer explanation

the patient should be weighed DAILY.

these patients are overloaded or "swimming" in water so they do not need to be drinking.

neuro checks are due to the sodium imbalance. these patients are hyponatremic. which is also why they are on seizure precautions.

serum and urine osmolality are how we assess if the patient is in DI or SIADH and if it is improving.

These patients are HYPERvolemic.... too much fluid. they do not need more by adding IV fluids.

The nurse is caring for a client with syndrome of inappropriate antidiuretic hormone (SIADH). What symptoms would the nurse expect to find? Select all that apply

• Elevated urine osmolality

• Decreased urine output

• Hypernatremia

• Edema

• Decrease serum osmolality

Answer explanation

SIADH - the client is swimming in fluid.

So your blood/serum is low in particles or diluted. While your urine is extremely concentrated.

Too much anti-diuretic hormone means they will hold on to the fluid.

3. A nurse is caring for a 3-day-old infant with a myelomeningocele who is scheduled for surgical repair. Which action will the nurse prioritize?

• 1. Perform sterile dressing changes over the myelomeningocele sac.

• 1. Ensure the infant is kept in a side-lying position.

• 1. Administer pain medication to keep the infant comfortable.

• 1. Assess the infant's lower extremities for flaccidity, movement and sensation.

Answer explanation

The most important priority for an infant with myelomeningocele is to prevent infection and protect the exposed spinal cord tissue. Performing sterile dressing changes over the myelomeningocele sac helps to minimize the risk of infection and neurological complications. The client is kept in side-lying post-operatively. All other options are also important aspects of care but are secondary to the prevention of infection and protection of the exposed neural tissue.

4. Which action should the nurse prioritize when caring for a child who presents with Gower's sign during a physical assessment?

• 1. Discuss end of life care decisions with family

• Administer corticosteroids and calcium

• Facilitate genetic counseling for the family

• 1. Implement measures to maintain mobility

Answer explanation

Mobility and safety are the priorities in initial diagnosis of Duchenne Muscular Dystrophy (DMD). Early intervention(s) that promote mobility is the early priority of DMD at this stage of presentation.

A patient with diabetes insipidus (DI) is prescribed desmopressin (DDAVP). Which of the following signs and symptoms would best indicate that the treatment is effective?

• Decreased urine output

• Dry mouth

• Increased thirst

A 68-year-old patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving the prescribed aspirin?

• The patient has a history of brief episodes of right-sided hemiplegia.

• The patient has atrial fibrillation.

• The patient has dysphasia

• The patient reports that symptoms began with a severe headache.

A patient has been diagnosed with encephalitis and is admitted to the hospital. Which nursing intervention is a priority in the care of this patient?

• Ensuring isolation precautions are in place

• Administering antipyretics as ordered

• Providing emotional support to the patient and family

• Implementing seizure precautions