A child with myelomeningocele, corrected at birth, is now 5 years old. Which is the priority nursing diagnosis for a child with corrected spina bifida at this age?
1. Risk for Altered Nutrition
2. Risk for Impaired Tissue Perfusion—Cranial
3. Risk for Altered Urinary Elimination
4. Risk for Altered Comfort
Correct Answer: 3
Rationale: A child with spina bifida will continue to have a risk for altered urinary elimination because the bowel and bladder sphincter controls are affected. Urinary retention is a problem, so bladder interventions are initiated early to prevent kidney damage. Risk for Altered Nutrition, Impaired Tissue Perfusion, and Altered Comfort are not problems once surgery has been performed to close the defect.
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The parents of a child recently diagnosed with Duchenne's muscular dystrophy want to know if their infant twin daughters should be tested for the disease too. Which response by the nurse is the most appropriate?
A. "No, Duchenne's muscular dystrophy is a sex-linked genetic disorder rarely affecting females." B. "No, infants the age of your daughters are too young to undergo testing for Duchenne's muscular dystrophy." C. "Yes, the earlier the diagnosis of any type of muscular dystrophy is made, the better the child's quality of life." D. "Yes, females are equally likely to have Duchenne's muscular dystrophy as are boys."
A patient with end-stage pancreatic cancer is admitted to the nursing unit. The patient is lethargic and jaundiced. What is the priority nursing care for this patient?
1. Manage nutrition. 2. Increase activity. 3. Manage comfort. 4. Understand the effects of high bilirubin levels.
You are bottle-feeding a baby. Which will not promote comfort and safety?
a. Assume a comfortable position. b. Hold the baby close to you. c. Tilt the bottle so the neck of the bottle and the nipple are always full. d. Prop the bottle and lay the baby down for the feeding.
The client with heart disease is scheduled to receive a daily morning dose of furosemide (Lasix). The nurse would report which of the following serum potassium levels to the health care provider before administering the daily dose?
1. 5.1 mEq/L 2. 4.2 mEq/L 3. 3.8 mEq/L 4. 3.0 mEq/L