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
The symptoms described by the parent - projectile vomiting followed by hunger - could indicate a serious condition such as pyloric stenosis, which is a narrowing of the opening from the stomach to the small intestine. This condition can lead to severe dehydration and requires immediate medical attention.
Choice B rationale
While burping can help to relieve gas and minor stomach discomfort, it would not address the underlying issue causing the projectile vomiting. This advice might be appropriate for a baby with simple colic or gas, but not for the symptoms described.
Choice C rationale
While oral rehydrating solutions can help to replace lost fluids and electrolytes, they do not address the underlying cause of the projectile vomiting. Furthermore, if the baby is vomiting frequently, they may not be able to keep down the solution.
Choice D rationale
Switching formulas can sometimes help babies who have allergies or intolerances to certain ingredients in their current formula. However, the symptoms described are not typical of a formula intolerance or allergy. Moreover, switching formulas without seeking medical advice can potentially lead to other complications.
Correct Answer is C
Explanation
Choice A rationale
While pain management is important following a cleft palate repair, it does not typically require immediate attention. Pain can be managed with appropriate analgesics and does not typically present an immediate risk to the patient’s health.
Choice B rationale
A patient refusing to ambulate following an appendectomy does not typically require immediate attention. Encouraging mobility is important for recovery, but refusal to ambulate does not present an immediate risk to the patient’s health.
Choice C rationale
Frequent swallowing following a tonsillectomy could indicate post-operative bleeding, which requires immediate attention. Post-tonsillectomy hemorrhage can be a life-threatening condition that requires immediate intervention.
Choice D rationale
While pain at the site of an IV infusion should be addressed, it does not typically require immediate attention unless there are signs of infection or infiltration. It does not present an immediate risk to the patient’s health.
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