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 C
Explanation
Choice A rationale
Encouraging self-care is important, but it may not be the immediate priority if the patient is exhibiting manic behavior and has recently experienced significant personal stressors.
Choice B rationale
Assisting the patient in identifying coping behaviors is a key part of treatment, but it may not be the immediate priority if the patient is at risk of self-harm.
Choice C rationale
Preventing self-directed violence is the priority action. Patients exhibiting manic behavior may have impaired judgment and impulse control, putting them at risk of self-harm.
Choice D rationale
Identifying support systems is important, but it may not be the immediate priority if the patient is at risk of self-harm.
Correct Answer is B
Explanation
Choice A rationale
Petechiae, or small red or purple spots on the skin caused by minor bleeding from broken capillary blood vessels, are an objective finding. They can be seen and evaluated by the nurse during a physical examination.
Choice B rationale
Nausea is a subjective symptom. It is something the patient experiences and reports, but it cannot be directly observed or measured by the nurse.
Choice C rationale
Cyanosis, or bluish discoloration of the skin due to poor circulation or inadequate oxygenation of the blood, is an objective finding. It can be observed by the nurse during a physical examination.
Choice D rationale
Fever is an objective finding. It can be measured by the nurse using a thermometer.
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