A home health nurse is developing a plan of care for a child diagnosed with hemiplegic cerebral palsy. Which of the following goals is the priority for the nurse to include in the plan of care?
Foster self-care activities.
Provide respite services for the parents.
Modify the environment.
Improve the client's communication skills.
The Correct Answer is A
A. Encouraging self-care activities helps promote independence and improve the quality of life for a child with hemiplegic cerebral palsy. It focuses on maximizing the child's potential for autonomy.
B. Respite care is important for caregiver support, but fostering self-care activities for the child is a higher priority for long-term development.
C. Modifying the environment is useful for safety and mobility but does not address the child’s ability to perform self-care, which is a key aspect of daily functioning.
D. While communication skills are important, fostering self-care activities takes precedence in
supporting the child’s independence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Tachycardia can occur with a brain tumor due to increased intracranial pressure and systemic stress responses.
B. Hyporeflexia is not a typical sign of a brain tumor. Hyperreflexia or changes in reflexes may be seen with central nervous system involvement.
C. Decreased appetite is more common due to nausea, vomiting, and other neurological symptoms associated with brain tumors.
D. A negative Babinski reflex is normal in children over 2 years old, and a positive Babinski reflex (extending the toes) may indicate neurological involvement, not a typical finding in brain tumors.
Correct Answer is D
Explanation
A. CPR is not typically necessary unless the child stops breathing or the heart stops during the seizure, which is rare.
B. Restraining a child during a seizure can cause injury. The focus should be on safety and protection, not restraint.
C. Lorazepam may be given if the seizure lasts too long, but ensuring safety is the priority action.
D. The nurse’s priority during a seizure is to ensure the child’s safety by removing hazardous items from the area and ensuring the child does not get injured.
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