The practical nurse (PN) is planning care for a child with heart failure. Which intervention should the PN give the greatest priority?
Monitor therapeutic level of phenytoin.
Increase fluid intake.
Cluster care to conserve the child's energy.
Restrict intake of foods high in sugar.
The Correct Answer is C
For a child with heart failure, the greatest priority for the practical nurse (PN) is to conserve the child's energy. Clustered care activities and rest periods will help to conserve the child's energy and minimize the workload on the heart.
Monitoring therapeutic levels of phenytoin (A) is not relevant to the care of a child with heart failure. Increasing fluid intake (B) is not a priority intervention for a child with heart failure, as excessive fluid intake can worsen heart failure. Restricting intake of foods high in sugar (D) may be necessary for a child with heart failure, but it is not the greatest priority for the PN to address.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Vitamin tablets are unlikely to cause significant harm to the esophagus if the child vomits after ingesting them. However, toilet bowl cleaner and kerosene are corrosive substances that can cause serious damage to the esophagus and other tissues if ingested.
An unknown substance cannot be evaluated for potential harm to the esophagus.
In any case, the mother should be advised to seek immediate medical attention for her child if they have ingested any potentially harmful substance.
The PN should also follow their facility's policies and procedures for managing cases of poisoning or suspected poisoning.
Correct Answer is A
Explanation
Baclofen is a muscle relaxant that can help relieve muscle spasms and manage conditions such as cerebral palsy¹. An assessment finding that indicates the drug is effective for a child with cerebral palsy would be decreased muscular spasticity. This means that the child's muscles are less stiff and rigid, which can improve their mobility and overall quality of life.
The other choices are incorrect because they are not directly related to the therapeutic effects of baclofen. Baclofen is a muscle relaxant that is used to relieve muscle spasms and stiffness. While it may have other effects on the body, its primary therapeutic effect is to decrease muscular spasticity.
- Increased appetite is not a known effect of baclofen.
- Sufficient urinary output is important for overall health, but it is not directly related to the effectiveness of baclofen.
- Fewer temper outbursts may be an indirect result of decreased muscular spasticity and improved mobility, but it is not a direct effect of baclofen.
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