The nurse is caring for a 14-year-old patient following myelography. What is the priority nursing action?

Observing for mental confusion or hallucinations.

Assessing motor function.

Monitoring for a decrease in spasticity.

Performing a follow-up MRI.

Answer and Explanation

The Correct Answer is C

Choice A reason: Observing for mental confusion or hallucinations is important, but it is not the priority action following myelography. While these symptoms can occur due to complications, they are less common than changes in muscle tone or motor function.

Choice B reason: Assessing motor function is crucial, but the priority is specifically monitoring for changes in muscle tone, such as a decrease in spasticity. Myelography can affect the spinal cord and nerve roots, potentially leading to changes in muscle tone and motor function.

Choice C reason: Monitoring for a decrease in spasticity is the priority nursing action. Myelography involves injecting contrast material into the spinal canal, which can affect the spinal cord and nerve roots. Monitoring for changes in muscle tone, such as a decrease in spasticity, helps detect potential complications early and allows for timely intervention.

Choice D reason: Performing a follow-up MRI is not the immediate priority nursing action. While follow-up imaging may be necessary to assess the results of the myelography, the immediate focus is on monitoring the patient's neurological status and ensuring their safety.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason: Squatting increases the return of venous blood back to the heart by compressing the large veins in the legs and abdomen. This position helps increase systemic vascular resistance, which in turn increases the blood flow to the lungs and improves oxygenation. Children with Tetralogy of Fallot often instinctively squat to relieve cyanotic spells, as it helps reduce the severity of symptoms by temporarily improving circulation.

Choice B reason: While a child might experience tachycardia during a cyanotic spell, squatting is not a position specifically associated with tachycardia. The primary purpose of squatting in children with Tetralogy of Fallot is to improve venous return and systemic vascular resistance, not to address tachycardia directly.

Choice C reason: Squatting does not decrease arterial blood flow away from the heart. Instead, it helps increase systemic vascular resistance, which improves pulmonary blood flow and oxygenation. This position assists in temporarily mitigating the effects of the heart defect by improving circulation.

Choice D reason: Squatting actually helps alleviate some of the workload on the heart by improving systemic vascular resistance and enhancing blood flow to the lungs. It is a compensatory mechanism that children with Tetralogy of Fallot use instinctively to manage cyanotic spells, and it does not increase the workload of the heart.

A. Three births at 37 to 42 weeks gestation. B. One birth between 20 weeks and 36 weeks 6 days gestation. C. One pregnancy loss before 20 weeks gestation. D. Three elective abortions. E. Four children currently living.

Correct Answer is ["A","B","C","E"]

Explanation

Choice A reason: The designation T3 indicates that the patient has had three full-term births, defined as births that occurred between 37 and 42 weeks of gestation. This is part of the standard obstetric history notation.

Choice B reason: The notation P1 means the patient has had one preterm birth, which is defined as a birth that occurred between 20 weeks and 36 weeks 6 days of gestation. This is an important part of understanding the patient's pregnancy history.

Choice C reason: A2 denotes that the patient has had two pregnancy losses before 20 weeks of gestation, which can include miscarriages or stillbirths. This is crucial for assessing the patient's reproductive health history.

Choice D reason: There is no indication from the notation G6, T3, P1, A2, L4 that the patient has had three elective abortions. Elective abortions would be noted differently in the patient's chart if they were part of the obstetric history.

Choice E reason: The notation L4 indicates that the patient currently has four living children. This is an important part of the patient's obstetric history as it gives insight into their childbearing outcomes.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is caring for a 14-year-old patient following myelography. What is the priority nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a child diagnosed with Tetralogy of Fallot who has positioned themselves in a squatting position. The nurse understands this position:

Correct Answer is A

Explanation

A nurse is reviewing the chart of a patient on the postpartum unit. The chart indicates the patient is a G6, T3, P1, A2, L4. What is the nurse's interpretation of this patient's obstetric history? Select All That Apply

Correct Answer is ["A","B","C","E"]

Explanation

The nurse is caring for an infant delivered one minute ago. The infant has no spontaneous respirations, no response to stimulus, is limp, pale, and has a heart rate of 99 beats per minute. How will the nurse document this infant's APGAR Score? Enter number only (no units).

The nurse is caring for a 4-year-old with cerebral palsy on an inpatient unit who is struggling to eat with regular utensils. What intervention will the nurse include in the plan of care?

The nurse is preparing to discharge a mother/baby couplet from the maternity unit. Which action by the parents requires further teaching?

The nurse is preparing for the care of a baby about to be delivered by caesarean section. What interventions will the nurse include in the plan of care? Select all that apply.

The nurse is assessing the urinary output of a patient 4 hours after a caesarean birth. The patient weighs 68 kg and the indwelling catheter bag measures 125 mL of urine. Which action will the nurse include in the plan of care?

The Labor and delivery triage nurse is assessing a primigravida at 38 weeks and 3 days gestation who reports uterine contractions that started 2 hours ago. Further examination reveals a cervix that is dilated at 1 cm and 20% effaced with intact membranes. What action will the nurse implement?

The clinic nurse is triaging postpartum patients. Which patient will the nurse have the healthcare provider see first?

The nurse is assessing an 18-month-old patient at a well-child visit. What findings would suggest a developmental delay?