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 B

Explanation

A. Reprimand the client about the potential damage that has occurred due to overexercising her body: Reprimanding the client is not a therapeutic approach and may worsen the client's feelings of guilt or shame. It's essential to approach clients with eating disorders with empathy and understanding rather than criticism.

B. Ask the client to agree to talk to a nurse whenever she feels the urge to exercise: Encouraging the client to communicate with a nurse when she feels the urge to exercise is a supportive intervention. This allows the nurse to provide assistance, encouragement, or distraction techniques to help the client cope with the urge in a healthier way.

C. Praise the client for looking at herself in a mirror: Praising the client for looking at herself in a mirror may inadvertently reinforce body image concerns or obsessive behaviors related to appearance. Instead of focusing on the client's appearance, it's important to encourage behaviors and thoughts that promote self-acceptance and body positivity.

D. Restrict the client from being weighed: Restricting the client from being weighed may exacerbate anxiety and control issues related to weight. It's essential to monitor the client's weight as part of their overall health assessment and treatment plan. However, discussions about weight should be conducted sensitively and in collaboration with the client, focusing on health rather than numbers.

A. Use frequent touch to provide client support. B. Directly tell the client that delusions are not real C. Limit the number of questions asked during assessments D. Place the client in seclusion visual hallucinations are present

Correct Answer is C

Explanation

A. Using frequent touch to provide client support: While touch can be comforting for some clients, individuals with schizophrenia, especially those experiencing paranoid delusions, may interpret touch as threatening or intrusive. Therefore, using frequent touch may exacerbate the client's paranoia and increase their distress.

B. Directly telling the client that delusions are not real: Directly challenging the client's delusions may cause them to become defensive or agitated. It is unlikely to be effective in changing the client's beliefs and may damage the therapeutic relationship. Instead, the nurse should use therapeutic communication techniques to explore the client's perceptions and validate their feelings while gently offering alternative perspectives.

C. Limiting the number of questions asked during assessments: Individuals experiencing frequent hallucinations and paranoid delusions may have difficulty concentrating and processing information. Limiting the number of questions asked during assessments reduces cognitive overload and helps prevent overwhelming the client. The nurse should prioritize asking clear, concise questions relevant to the client's immediate needs.

D. Placing the client in seclusion if visual hallucinations are present: Seclusion should only be used as a last resort and when absolutely necessary to ensure the safety of the client or others. It is not an appropriate intervention for managing hallucinations alone. Instead, the nurse should employ therapeutic communication techniques, provide a safe and supportive environment, and use prescribed medications as indicated to manage the client's symptoms.

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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?

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