The nurse is instructing the parents of a child who underwent a surgical repair of a myelomeningocele on how to change an occlusive dressing on the child’s back.
Which parental statement indicates understanding of the procedure?
The skin incision should be kept moist by periodically wetting the dressing.
When changing the dressing, the tape should be removed rapidly from the edges.
The incision should be protected from fecal contamination by an intact dressing.
To ensure easy removal of the sutures, the dressing should be kept dry.
To ensure easy removal of the sutures, the dressing should be kept dry.
The Correct Answer is C
Choice A rationale
Keeping the skin incision moist by periodically wetting the dressing is not the recommended care for a myelomeningocele surgical repair. The dressing needs to be kept dry to prevent infection and promote healing.
Choice B rationale
Removing the tape rapidly from the edges of the dressing during a change is not advised. This could potentially damage the skin and disrupt the healing process.
Choice C rationale
An intact dressing protects the incision from fecal contamination, which is crucial in preventing infection. This statement indicates an understanding of the procedure.
Choice D rationale
While it’s important to keep the dressing dry to ensure easy removal of sutures, it’s not the primary concern. The main goal is to protect the incision from contamination.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Purulent secretions are not typically associated with epiglottitis. Epiglottitis is an inflammation and swelling of the epiglottis and does not usually produce purulent secretions.
Choice B rationale
While a child with epiglottitis may appear anxious due to difficulty breathing, apprehension is not a specific symptom of epiglottitis.
Choice C rationale
A thick, muffled voice is a common symptom of epiglottitis. The inflammation and swelling of the epiglottis can affect the child’s voice, making it sound thick and muffled.
Choice D rationale
Wheezing is not typically a symptom of epiglottitis. While breathing difficulties are common in epiglottitis, they are usually due to the swelling of the epiglottis rather than constriction of the airways, which causes wheezing.
Correct Answer is ["B","E"]
Explanation
Choice A rationale
Both mother and daughter shedding tears of joy and gratitude may not necessarily indicate a healthy psychosocial adaptation. While it could be a sign of relief or happiness, it could also be a response to stress or fear.
Choice B rationale
The mother expressing her full support for her daughter can be a positive sign of psychosocial adaptation. Support from family members can play a crucial role in coping with and adapting to health-related challenges.
Choice C rationale
The mother appearing sad does not necessarily indicate a healthy psychosocial adaptation. It could be a normal reaction to her daughter’s discomfort, but it could also suggest that she is struggling to cope with the situation.
Choice D rationale
The patient giving birth to a healthy baby boy is not relevant to the question as it does not provide information about the psychosocial adaptation of the mother or the daughter.
Choice E rationale
The mother commending her daughter can be a positive sign of psychosocial adaptation. Positive reinforcement can help individuals cope with challenging situations and foster a sense of self-efficacy.
Choice F rationale
Both mother and daughter gently touching the baby’s cheek is not relevant to the question as it does not provide information about the psychosocial adaptation of the mother or the daughter.
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