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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Constipation is not typically associated with nephrotic syndrome. It may be related to dietary factors, dehydration, or other gastrointestinal issues.
Choice B reason: Increased abdominal girth can be an indication of nephrotic syndrome due to the accumulation of fluid in the abdomen (ascites) as a result of low albumin levels in the blood, which is a characteristic of this condition.
Choice C reason: Irritability can be a non-specific symptom and may be caused by a variety of factors. It is not a direct indication of nephrotic syndrome.
Choice D reason: Increased urinary output is not characteristic of nephrotic syndrome. In fact, decreased urine output may be observed due to the loss of protein in the urine and subsequent fluid retention in the body.
Correct Answer is A
Explanation
Choice A reason: Keeping electrical wires hidden from view is essential to prevent toddlers from pulling on them, which can lead to electrical burns or other injuries. It is a proactive measure to ensure a safe environment for children who are naturally curious and prone to exploring with their hands.
Choice B reason: Turning pot handles toward the front of the stove is dangerous as it increases the risk of toddlers reaching up and pulling hot contents onto themselves. The correct practice is to turn pot handles toward the back of the stove to keep them out of reach of children.
Choice C reason: Encouraging outdoor activities between the hours of 11:00 and 13:00 can expose toddlers to the sun's peak intensity, increasing the risk of sunburn. It is safer to encourage outdoor activities outside these hours when the sun is less intense.
Choice D reason: Setting the water heater to 60°C (140°F) is too high and poses a scalding risk. The recommended temperature to prevent burns is 49°C (120°F), which is hot enough for household use but not so hot as to cause immediate burns upon contact.
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