A home health nurse is developing a care plan for a child with hemiplegic cerebral palsy. What is the priority goal for the nurse to include in the care plan?
Improve the patient’s communication skills.
Foster self-care activities.
Provide respite services for the parents.
Enhance the patient’s mobility skills.
The Correct Answer is D
Choice A rationale
While improving the patient’s communication skills is an important goal in the care of a child with hemiplegic cerebral palsy, it is not the priority goal. The priority should be based on the child’s most immediate needs and the potential for harm if those needs are not met.
Choice B rationale
Fostering self-care activities is another important goal in the care of a child with hemiplegic cerebral palsy. However, it is not the priority goal. The priority should be based on the child’s most immediate needs and the potential for harm if those needs are not met.
Choice C rationale
Providing respite services for the parents is an important aspect of care, but it is not the priority goal for the child’s care plan. The priority should be based on the child’s most immediate needs and the potential for harm if those needs are not met.
Choice D rationale
Enhancing the patient’s mobility skills is the priority goal for a child with hemiplegic cerebral palsy. Hemiplegic cerebral palsy affects one side of the body, impacting the child’s mobility.
Therefore, interventions should focus on improving mobility to enhance the child’s independence and quality of life.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Polycystic ovarian syndrome is a hormonal disorder common among women of reproductive age. While it can lead to several complications, it does not significantly increase the risk of sepsis.
Choice B rationale
Cancer and certain treatments for cancer can weaken the immune system, increasing the risk of infections that could lead to sepsis.
Choice C rationale
Kallmann’s syndrome is a genetic condition that affects the production of a hormone involved in sexual development. It does not significantly increase the risk of sepsis.
Choice D rationale
Addison’s disease affects the adrenal glands and can disrupt the balance of hormones in the body, but it does not significantly increase the risk of sepsis.
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}
Explanation
The nurse should first: C. Administer additional morphine for pain management, followed by B. Reposition the client for comfort.
The client is reporting a pain level of 6 on a scale from 0 to 10, which indicates moderate to severe pain. As per the medication administration record, the client has an order for Morphine 4 mg IV bolus every 6 hours PRN for pain. Since the client is in pain, it would be appropriate to administer the morphine first to manage the pain.
After addressing the client’s pain, the nurse should then reposition the client for comfort. This can help to alleviate any discomfort or pressure points that may be contributing to the client’s pain. It’s also important to ensure the client’s safety and comfort by making sure the call light is within reach.
The options related to restraints (A and D for Response 1, and A, B, C, D for Response 2) are not relevant in this scenario as there is no indication in the provided information that the client is being restrained or that restraints are necessary. The client is drowsy but arouses easily to verbal stimuli and is able to follow simple commands, suggesting that they are not at risk of harming themselves or others, which would necessitate the use of restraints. Therefore, these options can be ruled out.
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