A home health nurse is developing a care plan for a child with hemiplegic cerebral palsy. What is the priority goal for the nurse to include in the care plan?

The correct answer is Choice D

Choice A rationale: Moral reasoning, including distinguishing right from wrong, requires abstract cognitive processing and internalization of social norms, typically emerging during the concrete operational stage around age 7. Toddlers are in Piaget’s sensorimotor to early preoperational phase, where egocentrism dominates and behavior is guided by immediate consequences rather than ethical principles. They lack the neurological maturity and social-cognitive integration required for moral discourse, making this milestone developmentally inappropriate for the toddler age group.

Choice B rationale: Performing simple chores involves task comprehension, motor coordination, and social cooperation, which are more consistently observed in preschool-aged children (4–5 years). Toddlers may imitate adult actions but lack sustained attention, impulse control, and fine motor precision needed for chore completion. Their psychosocial development is centered on autonomy and exploration, not structured responsibility. Expecting chore cooperation at this stage exceeds normative developmental expectations and may lead to frustration or behavioral resistance.

Choice C rationale: Printing letters and numbers requires advanced fine motor control, visual-motor integration, and symbolic cognition, typically achieved between ages 5 and 6. Toddlers are still developing basic hand-eye coordination and may engage in scribbling, but they lack the neuromuscular refinement and cognitive mapping needed for structured writing. Neurodevelopmental milestones do not support this skill in the toddler phase, making it scientifically inaccurate to expect printing behavior before preschool age.

Choice D rationale: By age 3, toddlers begin to tolerate brief separations from primary caregivers due to improved object permanence, emotional regulation, and social awareness. This aligns with Erikson’s autonomy vs. shame and doubt stage, where toddlers explore independence while maintaining secure attachment. Separation anxiety peaks around 9–18 months and typically declines by age 3. The ability to separate easily for short periods reflects healthy psychosocial development and is a scientifically appropriate expectation for toddlers.

Choice A rationale: Wearing a mask when caring for the client is not necessarily required in this scenario. The client has a fever, sore throat, and fatigue, which could be symptoms of many different illnesses. While it’s always important to use personal protective equipment (PPE) when necessary, the need for a mask isn’t specified in this scenario. The nurse should follow the hospital’s infection control guidelines and use PPE appropriately.

Choice B rationale: Encouraging the client to increase fluid intake is a good action for the nurse to take. The client appears slightly dehydrated, and increasing fluid intake can help alleviate this. Dehydration can make the body more susceptible to infection and can make recovery more difficult. By encouraging the client to drink more fluids, the nurse is helping to combat the client’s dehydration and potentially helping to speed up recovery.

Choice C rationale: Placing the client in a private room is not necessarily required based on the information provided. Unless the client’s condition is known to be contagious and requires isolation, a private room may not be necessary. The nurse should follow the hospital’s guidelines for room assignments.

Choice D rationale: Placing the client on contact precautions is not necessarily required based on the information provided. Contact precautions are used for patients who are known or suspected to have serious illnesses that are easily spread by direct patient contact or by indirect contact with items in the patient’s environment. The client’s symptoms could be due to a variety of illnesses, and it’s not clear from the information provided that contact precautions are necessary.

Choice E rationale: Monitoring the client’s temperature every 4 hours is a good action for the nurse to take. The client has had a fever for the past two days, so regular monitoring is necessary. By keeping track of the client’s temperature, the nurse can monitor the progress of the illness and the effectiveness of interventions.

Choice F rationale: Checking the client’s allergy history before administering the antibiotic is a crucial action for the nurse to take. This is a standard precaution to avoid any potential allergic reactions to the medication. Allergic reactions can range from mild to severe and can potentially be life-threatening. By checking the client’s allergy history, the nurse is ensuring the safety of the client.

Choice G rationale: Educating the client about the importance of completing the full course of antibiotics is a crucial action for the nurse to take. This is crucial to ensure the infection is fully treated and to prevent antibiotic resistance. Antibiotic resistance occurs when bacteria change in response to the use of antibiotics and become resistant to the drug. This can make infections harder to treat. By educating the client about the importance of completing the full course of antibiotics, the nurse is helping to combat the problem of antibiotic resistance.