test 4 case studies

Question 1

Upon delivery of an infant with myelomeningocele, which one of the following nursing actions may be contraindicated?

1. examination of the membranous cyst for intactness
2. diapering of the infant
3. keeping moist, sterile normal saline dressing on the defect
4. keeping the infant in the prone position

Answer 1

diapering the infant because you don’t want it constricting the area or causing breakdown

Question 2

Myelomeningocele closure should occur within?

Answer 2

should occur within 24 hours

Question 3

primary nursing goal for infant with myelomeningocele before surgery?

Answer 3

preventing skin breakdown (which prevents infection of the meningocele, which would cause harm and may cancel surgery)

Question 4

Best way to provide tactile stimulation needs before repair of the myelomeningocele?

Answer 4

Caressing and stroking child frequently while he is placed on a pillow across his mother’s lap

Question 5

Which of the following problems is most often associated with myelomeningocele?

1. Biliary atresia
2. Hydrocephalus
3. Craniosynostosis
4. Tracheoesophageal fistula

Answer 5

2. Hydrocephalus

Question 6

The nurse observes the myelomeningocele pt post op, check abdomen closely for development of?

Answer 6

4. Retaining urine is an indication of too much fluid, and reteintion can turn into a urinary tract infection

Question 7

After closure of the myelomeningocele, nursing care should include doing what priority assessment daily?

Answer 7

Measuring the head circumference daily

Question 8

myelomeningocele children are more at risk than other children for the development of?

Answer 8

latex allergy: because they are constantly exposed to latex so young

Question 9

sneezing, wheezing, and a rash over the lower pelvic area and genitals in a child are signs of ?

Answer 9

latex allergy

Question 10

what do anticholinergics in myelomeningocele pts. accomplish?

Answer 10

reduction of detrusor muscle tone and reduction of bladder pressure

Question 11

evaluates density, elasticity, and strength of the patella and calcaneus

Answer 11

quantitative ultrasound

Question 12

unable to diagnose osteoporosis until 25% to 40% of bone mass is lost

Answer 12

bone x-ray

Question 13

measures bone mass of spine, femur, forearm, and total body with radiation exposure

Answer 13

dual energy x-ray absorptiometry (DEXA)

Question 14

______continually deposits bone and __________ reabsorbs it, a process called _______

Answer 14

osteoblasts, osteoclasts, remodeling

Question 15

Hormone naturally secreted by the thyroid in response to increased amounts of serum calcium, inhibiting osteoclastic activity. Blocks effects of parathyroid hormone

Answer 15

calcitonin (calcimar)

Question 16

Dean is diagnosed by the health care provider as having nephrotic syndrome. Which of the following is not a symptom?

• proteinuria
• hypertension
• edema
• abdominal pain
• increased weight
• hypoalbuminemia

Answer 16

hypertension

Question 17

Which of the following nursing dx is of leas benefit in planning dean’s care?

1. impaired skin integrity related to edema, lowered body defenses
2. altered nutrition: less than body requirements related to decreased appetite
3. altered patterns of elimination related to obstruction
4. fluid vome excess related to fluid accumulation in tissues and third space

Answer 17

3. altered patterns of elimination related to obstruction