The parent of a child born with a myelomeningocele asks the nurse, "What did I do to deserve this?" Which response is most helpful?

"You didn't do anything wrong."

"Is there any particular reason why you think this is your fault?"

"This must be a very difficult time for you."

"With surgery, your baby should have a full recovery."

Answer and Explanation

The Correct Answer is C

The correct answer is Choice C: “This must be a very difficult time for you.”

Choice A rationale: Telling the parent “You didn’t do anything wrong” might seem comforting, but it doesn’t address the parent’s feelings of guilt or responsibility. It’s important to remember that myelomeningocele is a birth defect that occurs when the spine and spinal cord do not develop completely 1. It’s often not known why this happens, but it can be due to a combination of genetic and environmental factors 2. Therefore, it’s not something the parent did or didn’t do.

Choice B rationale: Asking “Is there any particular reason why you think this is your fault?” could potentially lead to a constructive conversation. However, it might also make the parent feel defensive or as if they need to justify their feelings. It’s crucial to approach this situation with empathy and understanding, acknowledging the parent’s feelings without making them feel judged.

Choice C rationale: Saying “This must be a very difficult time for you” is the most helpful response because it acknowledges the parent’s feelings and offers empathy. It doesn’t place blame or make assumptions. Instead, it opens up a space for the parent to express their feelings and concerns.

Choice D rationale: While it’s true that surgery can help manage the condition 1, saying “With surgery, your baby should have a full recovery” might be misleading. Myelomeningocele is the most severe form of spina bifida and can cause moderate to severe disabilities, such as muscle weakness, loss of bladder or bowel control, and/or paralysis 2. Each case is unique, and while some children may have less severe symptoms, others may require lifelong management. It’s important to provide accurate and realistic information.

Remember, it’s essential to approach these conversations with empathy and understanding. Parents dealing with a diagnosis of myelomeningocele are likely experiencing a range of emotions, and they need support and accurate information.

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Correct Answer is B

Explanation

A) Incorrect - While discussing the potential for asymptomatic partners is important, addressing the client's concerns and providing accurate information is more immediate.
B) Correct- Syphilis and other STIs are important public health concerns. The nurse should provide accurate information, answer questions, and correct any misconceptions the client might have. This approach supports the client's knowledge and understanding of their health condition and prevents the spread of misinformation.
C) Incorrect - While discussing contraceptives is relevant to sexual health education, it may not directly address the client's concerns about their prior infections.
D) Incorrect - Notifying local health departments is important for reporting communicable diseases, but it doesn't directly address the client's current situation and concerns.

A. Screen for orthostatic hypotension B. Provide oral care at least twice a day C. Monitor calcium levels D. Assess mental status regularly E. Assist the client to the bathroom F. Have an opioid agonist at the bedside

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

Explanation

Nursing Interventions for Client Starting Clonazepam:

The following nursing interventions are appropriate for the client starting clonazepam 0.25 mg PO every 12 hours:

a. Screen for orthostatic hypotension:

Rationale:

Clonazepam,like other benzodiazepines,can cause central nervous system (CNS) depression,which can lead to hypotension,particularly orthostatic hypotension.This occurs when blood pressure drops suddenly upon standing due to impaired autonomic nervous system regulation.
Screening for orthostatic hypotension involves measuring the client's blood pressure and heart rate while lying down and then again after standing for 3 minutes.A significant drop in blood pressure (systolic decrease of 20 mmHg or diastolic decrease of 10 mmHg) or increase in heart rate (over 20 beats per minute) indicates orthostatic hypotension.
Monitoring for orthostatic hypotension is crucial to prevent falls and other complications,especially in older adults or those with pre-existing cardiovascular conditions.

b. Provide oral care at least twice a day:

Rationale:

Clonazepam can cause dry mouth as a side effect,which can increase the risk of cavities,gum disease,and oral infections.
Regular oral care helps to remove plaque and bacteria,promoting oral hygiene and preventing complications.Providing oral care at least twice a day,especially before bedtime and upon waking,is essential.

d. Assess mental status regularly:

Rationale:

Clonazepam,while indicated for anxiety and insomnia,can paradoxically cause agitation,confusion,and even hallucinations in some individuals,particularly older adults or those with pre-existing psychiatric conditions.
Regular assessment of mental status helps to identify any adverse behavioral or cognitive changes early on.This includes monitoring for anxiety,depression,suicidal ideation,confusion,disorientation,hallucinations,and changes in sleep patterns.

e. Assist the client to the bathroom:

Rationale:

Clonazepam can cause drowsiness and dizziness,which can increase the risk of falls,especially in older adults or those with impaired mobility.
Assisting the client to the bathroom and providing support during toileting activities helps to prevent falls and injuries.

Choices not included:

c. Monitor calcium levels:

There is no specific indication for monitoring calcium levels with clonazepam use.

f. Have an opioid agonist at the bedside:

Clonazepam is not indicated for pain management and does not interact significantly with opioid analgesics.Therefore,having an opioid agonist readily available is not a necessary intervention for clonazepam initiation.

Additional Considerations:

Educate the client about the potential side effects of clonazepam,including drowsiness,dizziness,dry mouth,and cognitive changes.
Advise the client to avoid alcohol and other CNS depressants while taking clonazepam,as this can increase the risk of sedation and respiratory depression.
Instruct the client to take clonazepam exactly as prescribed and not to stop taking it abruptly,as this can lead to withdrawal symptoms.
Monitor the client's sleep patterns and adjust the medication schedule if necessary.

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The parent of a child born with a myelomeningocele asks the nurse, "What did I do to deserve this?" Which response is most helpful?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with the sexually transmitted infection (STI) syphilis. The client reports having had prior sexually transmitted infections. Which response should the nurse provide?

Correct Answer is B

Explanation

Exhibits The nurse reviews the physician's orders for clonazepam and gives the medication as ordered. What nursing interventions are appropriate for the client starting clonazepam? Select all that apply.

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

Explanation

Nursing Interventions for Client Starting Clonazepam:

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