The mother of a child with cerebral palsy (CP) asks the nurse if her child's impaired movements will worsen as the child grows.
Which response provides the best explanation?
CP is one of the most common permanent physical disabilities in children.
Brain damage with CP is not progressive but does have a variable course.
Severe motor dysfunction determines the extent of successful habilitation.
Continued development of the brain lesion determines the child's outcome.
The Correct Answer is B
Choice A rationale:
CP being one of the most common permanent physical disabilities in children is a general statement but does not directly address the mother's question about the progression of her child's impaired movements. It does not provide an explanation for the potential course of CP.
Choice B rationale:
Brain damage with CP is not progressive but does have a variable course. This response provides the best explanation to the mother's question. CP is a static neurological condition, which means that the initial brain injury that led to CP does not worsen over time. However, the functional abilities and impairments of a child with CP can vary widely and may change as the child grows and develops. Some children may improve with therapy and interventions, while others may have relatively stable impairments.
Choice C rationale:
Severe motor dysfunction determines the extent of successful habilitation is not entirely accurate. While the severity of motor dysfunction does play a role in the challenges a child with CP may face, it does not solely determine the extent of successful habilitation. Many factors, including early intervention, therapy, and individualized care, can influence a child's progress and potential for improvement.
Choice D rationale:
Continued development of the brain lesion determines the child's outcome is not an accurate statement. CP is primarily caused by non-pro
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Instill 3 mL of normal saline before suctioning. This choice is not appropriate for suctioning excessive drooling in a client with ALS. Instilling normal saline would introduce additional fluid into the oral cavity, potentially worsening the problem by increasing the amount of secretions. The goal of suctioning is to remove excess saliva and maintain a clear airway.
Choice B rationale:
Instruct the client to cough as the suction tip is removed. Instructing the client to cough during suctioning is not a recommended practice. It may cause discomfort and can lead to an increased risk of aspiration as the client might inhale while coughing during the procedure.
Choice C rationale:
Apply a water-soluble lubricant to the catheter. Applying a water-soluble lubricant to the suction catheter is a common practice to facilitate the passage of the catheter and minimize irritation to the client's oral tissues. While it is a helpful step, it is not the primary action that should be taken to ensure the safety of the procedure.
Choice D rationale:
Wear protective goggles while performing the procedure. This is the correct choice. When suctioning a client's oral cavity, especially when dealing with excessive drooling or secretions, it is essential for the nurse to wear protective goggles. These goggles protect the nurse's eyes from potential exposure to the client's bodily fluids, reducing the risk of infection transmission.
Correct Answer is D
Explanation
Choice A rationale:
Providing information about the client's healthcare power of attorney is not the most critical piece of information to report in this situation. The immediate concern is the client's change in mental status and potential medical emergency.
Choice B rationale:
While the reason for the client's admission is important background information, it is not the most urgent information to report in this situation. The priority is addressing the client's acute change in mental status.
Choice C rationale:
The nurse should be aware of the client's currently prescribed medications, but this information does not take precedence over the client's sudden onset of confusion and agitation. Immediate action is needed to address the client's altered mental status.
Choice D rationale:
Increasing confusion and agitation in a client who recently underwent ORIF of the right femur is a significant change in condition and may indicate a medical emergency such as infection, delirium, or other complications. This information should be provided first to alert the healthcare provider to the client's immediate needs.
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