A home health nurse is developing a plan of care for a child who has hemiplegic cerebral palsy.
Which of the following goals is the priority for the nurse to include in the plan of care?
Improve the client's communication skills.
Provide respite services for the parents.
Foster self-care activities.
Modify the environment.
The Correct Answer is D
The correct answer is d. Modify the environment.
Rationale for each choice:
Choice a. Improve the client's communication skills.
- Statement: While communication is important, it is not the priority for a child with hemiplegic cerebral palsy.
- Rationale: Hemiplegic cerebral palsy primarily affects motor skills, not communication abilities. While some children with hemiplegic cerebral palsy may have speech difficulties, it is not the most pressing concern in this case. Addressing environmental barriers to promote mobility and independence takes precedence.
Choice b. Provide respite services for the parents.
- Statement: Respite services can provide valuable support for parents, but they are not the priority in this case.
- Rationale: The focus of the care plan should be on the child's immediate needs and safety. Modifying the environment to enhance the child's functional abilities is crucial for their development and well-being.
Choice c. Foster self-care activities.
- Statement: Encouraging self-care is essential, but it requires a supportive environment.
- Rationale: Before promoting self-care activities, the nurse must ensure the child has the necessary accommodations and modifications in place to facilitate independence.
Choice d. Modify the environment.
- Statement: This is the priority goal for a child with hemiplegic cerebral palsy.
- Rationale: Modifying the home environment can significantly improve the child's mobility, safety, and ability to participate in daily activities. Examples of modifications include:
- Installing grab bars in the bathroom
- Widening doorways
- Removing tripping hazards
- Providing adaptive equipment such as special chairs or utensils
- Ensuring adequate lighting
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Semi-Fowler's. While this position can help with drainage, it is generally not the first choice immediately after VP shunt surgery.
B. Prone.This position is generally not recommended as it can cause discomfort and increase intracranial pressure.
C. Trendelenburg. This position is contraindicated as it can significantly increase intracranial pressure.
D. on the unoperated side. This position helps prevent pressure on the operative site and facilitates drainage of cerebrospinal fluid. It also reduces the risk of complications associated with increased intracranial pressure.
Correct Answer is B
Explanation
This is an important measure to prevent the spreading of impetigo to others and to other parts of the body, as the bacteria can survive on clothing and other objects12.
Choice A.
Keeping the child on droplet precautions at home is incorrect, as impetigo is not spread by respiratory droplets, but by direct contact with the sores or contaminated items.
Choice C.
Immunizing household contacts for the disease is incorrect, as there is no vaccine for impetigo, which is caused by different types of bacteria.
Choice D.
Giving the child a chlorine bath twice daily is incorrect, as chlorine can irritate the skin and worsen impetigo.
The recommended treatment is to wash the sores with soap and water and
apply antibiotic ointment or cream23.
Therefore, choice B is the best answer to this question.
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