A nurse is planning care for a 10-month-old infant who is 8 hr postoperative following cleft palate repair. Which of the following interventions should the nurse include in the infant's plan of care?

Feed the infant with a spoon for 48 hr.

Apply and release elbow restraints every hour.

Keep the infant supine

Suction the mouth with an oral suction tube.

Answer and Explanation

The Correct Answer is B

A. Feed the infant with a spoon for 48 hr.

Following cleft palate repair, infants may need special feeding techniques to minimize the risk of injury to the surgical site. Feeding with a spoon is a gentle method that reduces the risk of trauma to the repaired palate. However, it is typically recommended for a longer duration than 48 hours, often until the surgical site is fully healed and the healthcare provider provides further instructions. Therefore, this option is not entirely accurate.

B. Apply and release elbow restraints every hour.

Elbow restraints are commonly used postoperatively in infants to prevent them from inadvertently touching or scratching the surgical site. Releasing and reapplying the restraints every hour helps prevent skin breakdown and ensures adequate circulation to the extremities. This intervention helps maintain the integrity of the surgical repair and reduces the risk of complications. Therefore, this is an appropriate intervention for an infant post cleft palate repair.

C. Keep the infant supine

While keeping the infant supine may be necessary to prevent aspiration and promote comfort, it is not the primary intervention to address the surgical repair of the cleft palate. Positioning recommendations may vary based on the surgeon's preferences and the infant's specific needs, but supine positioning alone does not address the prevention of trauma to the surgical site.

D. Suction the mouth with an oral suction tube.

Suctioning the mouth with an oral suction tube may be indicated to maintain airway patency and remove secretions, especially if the infant has difficulty swallowing or clearing oral secretions effectively. However, it is not typically specified as a routine intervention following cleft palate repair unless there are specific concerns about airway compromise or excessive secretions. Therefore, while it may be necessary in some cases, it is not a standard intervention for all infants post cleft palate repair.

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Correct Answer is C

Explanation

A. Monitor the client closely to prevent self-mutilation: This action is not typically associated with dependent personality disorder. Dependent personality disorder is characterized by an excessive need to be taken care of, leading to submissive and clinging behaviors, rather than self-mutilation.

B. Give positive feedback when the client is assertive with staff or clients: While it is important to encourage and reinforce assertive behaviors, giving positive feedback alone may not be sufficient to address the underlying issues associated with dependent personality disorder. It's essential to provide comprehensive care that addresses the client's dependency needs and promotes healthy assertiveness.

C. Set limits to prevent exploitation of other clients: Clients with dependent personality disorder may exhibit behaviors that involve relying excessively on others and seeking caretaking from them. Setting limits helps prevent these clients from exploiting or overly burdening others with their needs, promoting boundaries and accountability within the therapeutic environment.

D. Discourage flamboyant or seductive behaviors: Flamboyant or seductive behaviors are not typical characteristics of dependent personality disorder. These behaviors are more commonly associated with other personality disorders, such as histrionic or borderline personality disorder. In dependent personality disorder, the focus is more on an excessive need for support and reassurance rather than attention-seeking behaviors.

A. The preschooler speaks in three-word sentences. B. The preschooler talks to himself when reading. C. The preschooler speaks in a nasally tone. D. The preschooler stutters when speaking. E. The preschooler mispronounces words.

Correct Answer is ["C","D","E"]

Explanation

Answer: C, D, E

A. The preschooler speaks in three-word sentences.
Speaking in three-word sentences is generally considered developmentally appropriate for a preschooler. By age 3 to 4, children typically use sentences that are more complex, but this is still within a normal range for early language development.

B. The preschooler talks to himself when reading.
Talking to oneself, especially during activities like reading, can be a normal behavior for preschoolers. This self-talk can actually be a part of cognitive development, helping them to process information and reinforce learning, and does not necessarily indicate a need for speech therapy.

C. The preschooler speaks in a nasally tone.
A nasally tone may suggest a speech issue such as a cleft palate or other resonance problems. If the child consistently exhibits this speech pattern, it could indicate a need for further evaluation by a speech therapist to determine the underlying cause and appropriate interventions.

D. The preschooler stutters when speaking.
Stuttering can be a significant speech concern that may require intervention. While some children experience normal disfluencies as they learn to speak, persistent stuttering that interferes with communication is a valid reason to refer the child for speech therapy.

E. The preschooler mispronounces words.
While mispronunciation can occur during language development, consistent or unusual mispronunciations beyond what is typical for the child’s age may indicate a speech sound disorder. If the mispronunciations affect the child's ability to communicate effectively, a referral to a speech therapist would be warranted for assessment and intervention.

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A nurse is planning care for a 10-month-old infant who is 8 hr postoperative following cleft palate repair. Which of the following interventions should the nurse include in the infant's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has dependent personality disorder. Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

A nurse is assessing a preschooler. Which of the following findings should indicate to the nurse a need for speech therapy? (Select all that apply.)

Correct Answer is ["C","D","E"]

Explanation

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