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 ["A","B"]
Explanation
Choice A rationale:
Fresh or frozen vegetables without sauce. Rationale: Fresh or frozen vegetables without sauce are excellent choices for a client with hypertension. These foods are low in sodium and can help manage blood pressure effectively. The absence of added sauces ensures that there is no hidden sodium content.
Choice B rationale:
Fruits without sauce. Rationale: Fruits without sauce are also suitable for clients with hypertension. They are naturally low in sodium and provide essential nutrients that can support blood pressure control. The absence of sauce ensures that no additional sodium is added.
Choice C rationale:
Pickled olives. Rationale: Pickled olives are high in sodium due to the pickling process. Therefore, they are not recommended for clients with hypertension as they can lead to an increase in blood pressure.
Choice D rationale:
Canned soup. Rationale: Canned soup often contains high levels of sodium, which is not suitable for clients with hypertension. Excessive sodium intake can contribute to elevated blood pressure and should be avoided.
Choice E rationale:
Cottage cheese. Rationale: Cottage cheese is generally considered acceptable for clients with hypertension, especially if it is the low-sodium or reduced-sodium variety. However, it is not as strongly recommended as fresh or frozen vegetables and fruits without sauce.
Correct Answer is A
Explanation
This is the correct answer because it is the most relevant and respectful question to ask the client next. Asking about the onset of the voices can help the practical nurse (PN) determine the possible causes and triggers of the client's hallucinations, which are sensory perceptions that occur without external stimuli. Hallucinations can be caused by various factors, such as mental disorders, substance abuse, medication side effects, physical illnesses, sleep deprivation, or stress. The PN should ask about the frequency, duration, and content of the voices, as well as the client's response to them. The PN should also assess the client's mood, behavior, cognition, and insight. The PN should use a calm, supportive, and nonjudgmental approach when communicating with the client who is experiencing hallucinations.
a) "Are you planning to obey the voices?"
This is not the correct answer because it is not a priority question to ask the client next. Asking about the client's intention to obey the voices can help the PN assess the risk of harm to self or others, which is an important aspect of safety. However, this question may also imply that the PN believes or validates the voices, which may reinforce the client's delusions or false beliefs. The PN should ask about the client's plan to obey the voices only after establishing rapport and trust with the client, and after assessing the nature and content of the voices.
b) "Have you taken any hallucinogens?"
This is not the correct answer because it is not a respectful question to ask the client next. Asking about the client's substance use can help the PN identify the possible causes of hallucinations, as some drugs such as LSD, psilocybin, or ketamine can induce hallucinogenic effects. However, this question may also sound accusatory or confrontational, which may offend or alienate the client. The PN should ask about the client's substance use in a sensitive and nonthreatening manner, and after obtaining informed consent and ensuring confidentiality.
d) "Do you believe the voices are real?"
This is not the correct answer because it is not a helpful question to ask the client next. Asking about the client's belief in the reality of the voices can help the PN assess the level of insight or awareness that the client has about their condition. However, this question may also challenge or invalidate the client's perception, which may cause defensiveness or resistance. The PN should avoid arguing or disagreeing with the client about their hallucinations, as this may damage the therapeutic relationship. The PN should acknowledge and accept the client's experience without endorsing or reinforcing it.
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