The client is a 7-year-old with spastic cerebral palsy (CP) admitted to pre-op for heel cord lengthening. Child has cognitive and speech delays. Experiences absent seizures numerous times daily according to parent. The nurse is developing the plan of care for the child.
To provide atraumatic care for this child post-operatively, what will be a priority?

Pain assessments

Antibiotics

Occupational therapy

Wound care

Physical therapy

Answer and Explanation

The Correct Answer is A

Assessing and managing pain is a crucial aspect of providing atraumatic care for any post-operative patient, including a child with spastic cerebral palsy. It is important to monitor and assess the child's pain levels regularly to ensure their comfort and

well-being. Pain can be particularly challenging to assess in a child with cognitive and speech delays, so the nurse should use appropriate pain assessment tools and also consider nonverbal cues, changes in behavior, and physiological indicators of pain.

While antibiotics may be prescribed if there is an infection present, it is not mentioned as a priority in this specific scenario. The focus is on providing atraumatic care post-operatively.

Occupational therapy, physical therapy, and wound care are all important components of the child's overall care, but they may not be the immediate priority post-operatively. The child's specific needs and surgical procedure will determine when these interventions are appropriate and can be incorporated into the plan of care as needed. However, addressing pain is of utmost importance in the immediate post-operative period.

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Correct Answer is C

Explanation

In this scenario, the child with a congenital heart defect is presenting with a fever and an

earache. The mother expresses concern about the child's weight and height being at the 5th percentile for his age. Given the child's medical history of a congenital heart defect, it is important for the nurse to address the mother's concerns and provide an accurate response.

The response that states "His smaller size is probably due to the heart disease" is appropriate because children with congenital heart defects may experience growth and developmental delays. Heart defects can affect the child's ability to obtain sufficient nutrients for growth, leading to slower weight and height gain. By acknowledging the relationship between the child's heart disease and his smaller size, the nurse provides the mother with an explanation for the child's growth pattern and helps alleviate concerns.

The other response options are not appropriate or helpful. Asking about the child's mental abilities or implying that the mother has not been feeding the child adequately can be perceived as judgmental or dismissive.

A. Observe the color of urine. B. Assess skin turgor. C. Measure body temperature. D. Check for pedal edema.

Correct Answer is A

Explanation

To monitor for adverse effects from prasugrel, a platelet inhibitor, the nurse should prioritize assessing for bleeding or abnormal bleeding tendencies. Therefore, observing the color of urine is the most important assessment among the options provided.

Changes in urine color, such as the presence of blood or dark-colored urine, can indicate internal bleeding or bleeding in the urinary tract, which can be a potential adverse effect of platelet inhibitors. It is crucial to monitor for signs of bleeding to ensure the client's safety and intervene promptly if necessary.

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Naxlex Comprehensive Predictor Exams

A 3-year-old boy with a congenital heart defect is brought to the clinic by his mother because he has a fever and an earache. During the assessment, the mother asks the nurse why her child is at the 5th percentile for weight and height for his age. Which response is best for the nurse to provide?

Correct Answer is C

Explanation

Correct Answer is A

Explanation

A client with diabetes insipidus (DI) has an average urinary output of 500 ml. of dilute urine every hour for the last 4 hours. Which laboratory test is most important for the nurse to monitor?

An older client is being admitted to a short-term rehabilitation facility after a long hospitalization. The nurse is performing a functional assessment with the client. Which action should the nurse implement?

What age-related factors may factor into this client's wound healing? Select all that apply.

While changing a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

The nurse is planning to administer two medications to a client at 0900. Which property of the drugs, if shared by both drugs, indicates a need to closely monitor the client for drug toxicity?

A client develops urticaria on the trunk and neck shortly after a secondary infusion of piperacillin is initiated. In which, order should the nurse implement these interventions? (Arrange the actions in order of priority, with the highest priority first, and least priority last or at the bottom.)