A nurse is collecting data from a child who has muscular dystrophy. Which of the following findings should the nurse expect? (Select all that Apply)
Spinal defect and sac-like protrusion
Muscular weakness in lower extremities
Kyphosis of the lower spine
Purposeless, involuntary, abnormal movements
Unsteady waddling gait
Correct Answer : B,C,E
Choice A rationale
Spinal defects and sac-like protrusions are not typically associated with muscular dystrophy. They are more commonly seen in conditions like spina bifida.
Choice B rationale
Muscular weakness in the lower extremities is a common symptom of muscular dystrophy. This is due to the progressive degeneration of muscle fibers, which leads to weakness and loss of muscle mass.
Choice C rationale
Kyphosis of the lower spine can be a complication of muscular dystrophy. As the muscles supporting the spine weaken, the spine can curve abnormally, leading to kyphosis.
Choice D rationale
Purposeless, involuntary, abnormal movements are not typically associated with muscular dystrophy. These symptoms are more commonly seen in neurological conditions like Huntington’s disease or certain types of cerebral palsy.
Choice E rationale
An unsteady waddling gait is often seen in individuals with muscular dystrophy. This is due to the progressive weakness and loss of muscle mass in the lower extremities.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Pediculosis capitis, also known as head lice, is a common condition in children. One of the definitive indications of this condition is the presence of firmly attached white particles on the hair, which are the eggs or “nits” of the lice.
Choice B rationale
While itching and scratching of the head can be a symptom of pediculosis capitis, it is not a definitive indication as it can be caused by other conditions such as dandruff or dermatitis.
Choice C rationale
Patchy areas of hair loss are not typically associated with pediculosis capitis. They could indicate a different condition, such as alopecia areata or tinea capitis.
Choice D rationale
Thick yellow-crusted lesions on a red base are not a symptom of pediculosis capitis. This description is more consistent with impetigo, a bacterial skin infection.
Correct Answer is C
Explanation
Choice A rationale
While maintaining a saline-lock can be important for administering medications or fluids, it is not the priority action. The nurse’s priority should be to assess the child’s condition and intervene to prevent complications.
Choice B rationale
A no-salt-added diet may be recommended for some children with acute glomerulonephritis to help manage fluid balance and blood pressure. However, this is not the priority action. The nurse’s priority should be to assess the child’s condition and intervene to prevent complications.
Choice C rationale
This is the correct answer. Checking the child’s weight daily is a priority action because weight changes can indicate fluid retention or loss, which can affect kidney function. Regular weight checks can help guide treatment decisions and monitor the effectiveness of interventions.
Choice D rationale
Educating the parents about potential complications is important, but it is not the priority action. The nurse’s priority should be to assess the child’s condition and intervene to prevent complications.
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