The nurse is caring for an infant born with a myelomeningocele. Which should the nurse assess in this patient?
A) Vision
B) Level of pain
C) Voiding pattern
D) Tonic neck reflex
C
Feedback:
: A myelomeningocele is the defect that is equated with "spina bifida" and is the most common birth defect affecting the central nervous system. In a meningomyelocele, the meninges protrude through the vertebrae and the spinal cord usually ends at the point of protrusion. Motor and sensory function will be decreased or absent beyond this point. The child will have loss of bowel and bladder control and urine, and stools will continually dribble because of lack of sphincter control. This defect is not known to affect vision. Assessing for pain is not a priority with this defect. This defect does not affect the neck region of the spinal cord.
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When discussing the economics of health care with colleagues, the community health nurse addresses macroeconomic theory. Which of the following would the nurse include?
A) Quantity of services available B) Consumer's willingness to buy services C) Aggregate perspective of economic stability D) Allocation of the available resources
You are assessing a healthy adolescent girl as a part of a sports physical. When it comes time to listen to her heart and lungs, you decide to:
A) Perform auscultation with the stethoscope placed firmly over her clothing to protect her privacy. B) Perform auscultation by holding the diaphragm lightly on her clothing to eliminate the "scratchy noise." C) Perform auscultation with the diaphragm placed firmly on her skin to minimize extra noise. D) Defer the exam, because she is healthy and it may agitate the girl.
A patient with severe back pain from spinal stenosis is prescribed propoxyphene. Which of the following should be included in the nurse's instruction for this patient?
1. Ways to reduce the risk of falls and subsequent fractures 2. The need to take this medication on an empty stomach 3. The need to take this medication first thing in the morning with a full glass of water 4. The need to sit or stand for 30 minutes after taking this medication
An older client complains that, "All the food here tastes bitter." What is a nurse's best response? Select all that apply.
A) "Sensitivity for bitter remains intact in older clients, but sweet declines." B) "Perceptivity for sugar and salt declines with age, and what's left is bitter." C) "Make sure to brush your tongue with your teeth to increase taste sensation." D) "Let me know if your mouth ever gets dry; that could make taste indistinct." E) "I will check the kitchen to see what seasonings they are putting in the food."