A nurse is planning to complete dressing changes for an adolescent who has multiple burn injuries. Which of the following interventions addresses the greatest risk to the client?

Choice A reason: This is not the correct instruction to include in the discharge teaching. Perform clean intermittent catheterization every 8 hours is a possible intervention for infants who have neurogenic bladder dysfunction due to spinal cord injury or spina bifida. However, not all infants who have myelomeningocele repair require catheterization. The nurse should assess the infant’s bladder function and teach the guardian how to perform catheterization if needed.

Choice B reason: This is not the correct instruction to include in the discharge teaching. Use a rectal thermometer to stimulate the passage of stool twice per day is a possible intervention for infants who have neurogenic bowel dysfunction due to spinal cord injury or spina bifida. However, not all infants who have myelomeningocele repair require rectal stimulation. The nurse should assess the infant’s bowel function and teach the guardian how to manage constipation or fecal incontinence if needed.

Choice C reason: This is not the correct instruction to include in the discharge teaching. Anticipate gradual loss of function in the lower extremities is a possible outcome for infants who have myelomeningocele repair, depending on the location and severity of the defect. However, the nurse should not assume that the infant will lose function in the lower extremities. The nurse should monitor the infant’s motor and sensory development and provide appropriate interventions to promote mobility and prevent complications.

Choice D reason: This is the correct instruction to include in the discharge teaching. Check toys and pacifiers for the presence of latex is an important precaution for infants who have myelomeningocele repair, as they are at risk of developing latex allergy due to repeated exposure to latex products during surgery and medical procedures. The nurse should teach the guardian how to identify and avoid latex-containing items and how to recognize and treat signs of allergic reaction.

Choice A reason: Loosening tight clothing around the child's neck is important to ensure that the child can breathe easily and to prevent any additional discomfort or injury during the seizure.

Choice B reason: It is not recommended to firmly hold the child's arms to one side as this can cause injury. Instead, the nurse should ensure the child's safety by clearing the area of any hard or sharp objects.

Choice C reason: Placing a pillow under the child's head can help to protect the head from injury during the seizure. It provides a soft cushion to prevent the child from hitting their head on hard surfaces.

Choice D reason: Inserting a tongue blade into the child's mouth is not advised as it can cause injury to the child's mouth or teeth, and there is a risk of the child biting down and breaking the blade.

Choice E reason: Clearing the area of hard objects is crucial to prevent injury to the child during the seizure. Removing any potential hazards ensures a safer environment for the child to move without harm.