When assessing a newborn girl with salt-wasting congenital adrenal hyperplasia due to 21 hydroxylase deficiency, the nurse notes that the infant has an enlarged clitoris. Which intervention should the nurse implement?
Review transcutaneous bilirubin levels with a bilirubinometer.
Observe and palpate newborn's breast tissue for enlargement.
Assess for signs of fluid retention and bilateral pedal edema.
Explain to the mother that the finding is due to increased androgen.
The Correct Answer is D
A) Incorrect- Reviewing transcutaneous bilirubin levels is unrelated to the presence of an enlarged clitoris. Bilirubin levels are typically assessed to monitor jaundice in newborns.
B) Incorrect- Observing and palpating breast tissue for enlargement is not relevant to the condition of salt-wasting congenital adrenal hyperplasia. Breast tissue enlargement would not be associated with this hormonal disorder.
C) Incorrect- Assessing for signs of fluid retention and bilateral pedal edema is important for monitoring for other conditions, but it is not relevant to the enlarged clitoris seen in this specific scenario.
D) Correct- Salt-wasting congenital adrenal hyperplasia is a genetic disorder that results in a deficiency of certain enzymes required for cortisol and aldosterone production. This deficiency leads to an overproduction of androgens, which can cause virilization of female external genitalia. The enlarged clitoris is a result of increased androgen levels. Explaining this finding to the mother provides her with accurate information about the condition and its effects on the infant's anatomy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Incorrect- Clarify reality with the client about delusional thoughts: Attempting to correct the client's delusional thoughts might cause frustration and agitation. Clients with Alzheimer's disease may have difficulty comprehending and retaining reality-based information.
B) Incorrect- Reduce the client's interaction with others during the day: Social interaction is important for clients with Alzheimer's disease to maintain engagement and prevent feelings of isolation. Reducing interaction could worsen their emotional well-being.
C) Correct- Clients with Alzheimer's disease often experience cognitive impairments and may have delusional thoughts or confusion, such as believing deceased loved ones are still alive. Nonpharmacological interventions are crucial to provide comfort and manage challenging behaviors. Distraction techniques involve redirecting the client's attention away from the delusion and onto a different, engaging activity. This can help decrease distress and anxiety related to their delusional thoughts. Therapeutic communication skills, such as validating the client's feelings and emotions, can also be beneficial. Simply telling the client that their mother is deceased may cause distress and confusion. Instead, providing comfort, empathizing with their emotions, and redirecting their focus can be more effective in managing the situation.
D) Incorrect- Awaken the client for reality checks every 4 hours at night: Disrupting the client's sleep schedule could lead to increased confusion and restlessness. It's important to provide a calm and consistent sleep routine for individuals with Alzheimer's disease.
Correct Answer is C
Explanation
It is important to determine if the client has any plans or intentions to act upon the voices' instructions. This information helps gauge the level of risk and guides further interventions and safety measures.
While the other questions may also be important to ask during the assessment, determining if the client believes the voices are real and when the voices began can provide valuable information about the client's perception and the duration of the symptoms. Asking about the use of hallucinogens is relevant to identify potential substance-induced causes of the hallucinations. However, assessing the client's intent and potential for harm is the priority in this situation.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.