A home health nurse is doing the first intake visit for a child who has hemiplegic cerebral palsy. When developing a plan of care for this child, which of the following goals is the priority for the nurse to include in the plan of care?

Provide activities of daily living for the child

Modify the home for safety

Provide respite services for the parents

Improve the client's communication skills

Answer and Explanation

The Correct Answer is B

A. While providing assistance with activities of daily living is important, ensuring the child's environment is safe is a higher priority to prevent injuries.
B. Modifying the home for safety is the priority because children with hemiplegic cerebral palsy have motor impairments that increase their risk for accidents and injuries. A safe environment is essential for the child’s well-being.
C. Providing respite services for the parents is beneficial for the family’s overall stress management, but it is not as immediate a concern as ensuring the child’s safety.
D. Improving communication skills is important for the child's overall development, but ensuring a safe living environment takes precedence to prevent potential harm.

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Correct Answer is C

Explanation

A. While lidocaine cream can provide some pain relief, it is not the most effective method for relieving pain during a bone marrow aspiration and biopsy.
B. Relaxation techniques can help with anxiety but are not sufficient alone to relieve pain during this procedure.
C. Conscious or unconscious sedation is the most effective intervention to relieve pain and discomfort during a bone marrow aspiration and biopsy. This method ensures that the child is adequately sedated and comfortable throughout the procedure.
D. Acetaminophen can help with minor pain but is not effective enough for the pain associated with a bone marrow aspiration and biopsy.

A. Document the Information as this is an expected finding. B. Encourage the child to cough, and deep breathe C. Immediately report this finding as this is life threatening D. Assist the child to a sitting position to prove drainage

Correct Answer is C

Explanation

A. Documenting the information without taking action is inappropriate as lack of drainage could indicate a serious complication.
B. Encouraging the child to cough and deep breathe might be beneficial, but immediate reporting of this finding is critical.
C. Lack of drainage from the chest tubes following cardiac surgery can be life-threatening, indicating possible cardiac tamponade or tube occlusion. Immediate reporting is necessary for prompt intervention.
D. Assisting the child to a sitting position is not the priority; immediate evaluation by the healthcare team is required.

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A home health nurse is doing the first intake visit for a child who has hemiplegic cerebral palsy. When developing a plan of care for this child, which of the following goals is the priority for the nurse to include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse understands that which of the following interventions is the MOST effective at relieving pain and discomfort during a bone marrow aspiration and biopsy for a school-aged child?

Correct Answer is C

Explanation

The nurse is caring for a preschool aged child immediately following an open repair of a Ventricular Septal Defect. There has been no drainage from the mediastinal chest tubes in the last 2 hours. Based on this finding what will be the nurse's priority intervention?

Correct Answer is C

Explanation

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