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.Log rolling is an appropriate technique to reposition a postoperative scoliosis repair patient as it minimizes stress on the spine and helps maintain spinal alignment. Patients need frequent repositioning to prevent pressure ulcers and promote comfort, but every 4 hours may not be frequent enough; typically, every 2 hours is recommended.
b.Protective isolation is not typically required for patients undergoing scoliosis surgery unless they have specific risk factors for infection (e.g., immunocompromised status). Standard postoperative care focuses on monitoring for infection at the surgical site rather than isolation unless indicated by the patient's condition.
c.While it’s important to elevate the head of the bed to assist with breathing and comfort, after scoliosis surgery, the head of the bed is generally elevated to 30-45° to facilitate lung expansion and reduce the risk of aspiration. However, it should be ensured that this angle does not compromise spinal alignment, especially in the early postoperative period.
d.The use of a patient-controlled analgesia (PCA) pump is an appropriate intervention for pain management after scoliosis surgery. It allows the patient to self-administer pain medication within prescribed limits, leading to more effective pain management, improved patient satisfaction, and potentially reduced need for supplemental analgesics.
Correct Answer is D
Explanation
a.While involving mental health professionals can be part of a broader intervention plan, it is not the immediate priority in cases of suspected abuse. The nurse must first address the immediate safety concerns and follow the required reporting procedures.
b.Separating the child from the parents without proper authority or immediate threat can escalate the situation and may not be legally permissible. This action should be taken by authorities with the legal power to do so if deemed necessary.
c.Nurses are mandated reporters, which means they are legally required to report any suspected child abuse to the appropriate authorities immediately. This action ensures that the child’s safety is prioritized and that a proper investigation can be initiated however,obtaining a detailed history is the priority.
d.When a nurse observes several bruises on a child, the initial action should be toobtain a detailed history. This step allows the nurse to gather information about the circumstances surrounding the bruises, assess for any potential signs of abuse, and determine the most appropriate course of action.
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