A nurse is creating a plan of care for an adolescent who has muscular dystrophy. Which of the following interventions should the nurse include in the plan?
Recommend the adolescent use a wheelchair to prevent stress on the lower extremities.
Avoid influenza and pneumococcal vaccines for 24 months.
Initiate a referral for chest physiotherapy every 4 hours.
Encourage the adolescent to perform incentive spirometry to maintain lung capacity.
Correct Answer : A,C,D
Choice A reason: Recommending the use of a wheelchair can help prevent stress on the lower extremities, which is important for an adolescent with muscular dystrophy. This condition can lead to muscle weakness and using a wheelchair can aid in mobility and independence.
Choice B reason: Avoiding influenza and pneumococcal vaccines is not recommended. Vaccinations are important for preventing infections, especially in individuals with compromised health conditions like muscular dystrophy.
Choice C reason: Initiating a referral for chest physiotherapy every 4 hours can be beneficial for an adolescent with muscular dystrophy. This therapy can help clear mucus from the lungs and improve respiratory function, which is often compromised in this condition.
Choice D reason: Encouraging the adolescent to perform incentive spirometry is important to maintain lung capacity. Muscular dystrophy can affect the muscles used for breathing, and incentive spirometry can help strengthen these muscles and improve respiratory health.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Preparing to administer a potassium IV bolus is not typically indicated in sickle cell crisis unless there is a documented potassium deficiency. Potassium levels must be carefully monitored to avoid hyperkalemia.
Choice B reason: Providing hydration both orally and intravenously is crucial in managing sickle cell crisis. Hydration helps to reduce blood viscosity and improve circulation, which can alleviate the pain and prevent further sickling of red blood cells.
Choice C reason: Requesting a prescription for meperidine is not recommended for pain management in sickle cell crisis due to the risk of seizures and other side effects. Other pain medications, such as morphine, are preferred.
Choice D reason: Administering multiple units of platelets is not a standard treatment for sickle cell crisis. Platelet transfusion is typically reserved for patients with thrombocytopenia or active bleeding, not for sickle cell crisis.
Correct Answer is D
Explanation
Choice Areason: Decreased urine output is not directly related to ventriculoperitoneal shunt displacement. It may indicate other issues such as dehydration or kidney problems.
Choice Breason: Increased sleeping is not a specific indicator of shunt displacement. While it may be a concern if there are significant changes in the child's sleep patterns, it is not a definitive sign of this complication.Choice C reason: Hyperactive bowel sounds are not associated with shunt displacement. They may indicate gastrointestinal issues but are not relevant to the function of a ventriculoperitoneal shunt.
Choice D reason: An elevated temperature can be an indicator of shunt displacement, as it may suggest an infection or other complications related to the shunt. Parents should be aware of this sign and seek medical attention if it occurs.
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