A nurse is caring for a 3-year-old child who has had 160 mL of urine output over the past 8-hour period.

The child weighs 33 lb.

Which of the following actions should the nurse take?

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 adequatelighting

Individuals with spina bifida who are paralyzed from the waist down may have difficulty emptying their bladder completely and may need to perform intermittent catheterization.
The frequency of catheterization can vary depending on the individual’s needs, but it is typically performed every 3-6 hours or 4-6 times per day.
Choice A, “I do wheelchair exercises while watching TV,” is a positive statement because exercise is important for overall health and well-being.
Choice B, “I carry a water bottle with me because I drink a lot of water,” is also a positive statement because staying hydrated is important for overall health.
Choice C, “I use a suppository every night to have a bowel movement,” is not necessarily an indication for further teaching because some individuals with spinal bifida may need to use bowel management techniques such as suppositories to help regulate bowel movements.