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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale

Acute laryngotracheobronchitis, also known as croup, is a common childhood condition that is usually caused by a viral infection. The main symptom is a distinctive barking cough. A cool mist tent can help to soothe the inflamed airways and reduce stridor, which is a high-pitched,

wheezing sound caused by disrupted airflow. Therefore, decreased stridor would indicate that the treatment has been effective.

Choice B rationale

While a decreased temperature might indicate a resolution of any underlying infection, it is not directly related to the effectiveness of a cool mist tent in treating acute laryngotracheobronchitis.

Choice C rationale

A barking cough is a symptom of acute laryngotracheobronchitis and does not indicate treatment effectiveness.

Choice D rationale

Improved hydration is important but is not a direct indicator of the effectiveness of the cool mist tent.

A. Initiate oxygen therapy. B. Obtain a blood sample. C. Attach the leads for a 12-lead ECG. D. Insert an IV catheter.

Correct Answer is A

Explanation

Choice A rationale

The priority action for a nurse when caring for a patient exhibiting symptoms of a myocardial infarction is to initiate oxygen therapy. Oxygen therapy is crucial because it increases the amount of oxygen in the blood, which can help reduce the heart’s workload and relieve pain. This intervention is aimed at reducing myocardial oxygen demand and improving oxygen supply to the ischemic myocardium.

Choice B rationale

Obtaining a blood sample is important as it can help diagnose a myocardial infarction. Blood tests can measure levels of certain proteins, such as troponins, in the bloodstream that can indicate heart muscle damage. However, this is not the immediate priority when compared to initiating oxygen therapy.

Choice C rationale

Attaching the leads for a 12-lead ECG is an important step in the assessment of a patient with suspected myocardial infarction. An ECG can show whether the heart muscle has been damaged and where the damage has occurred. However, this should be done after initiating oxygen therapy.

Choice D rationale

Inserting an IV catheter is a necessary step in the management of a myocardial infarction. It allows for the administration of medications and fluids as needed. However, it is not the first priority. The first priority is to stabilize the patient, which includes initiating oxygen therapy.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a toddler who has acute laryngotracheobronchitis and has been placed in a cool mist tent. Which of the following findings would indicate that the treatment has been effective?

Correct Answer is A

Explanation

A nurse in the emergency department is attending to a patient exhibiting symptoms of a myocardial infarction. Which of the following actions should the nurse prioritize?

Correct Answer is A

Explanation

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