The client is a 7-year-old with spastic cerebral palsy (CP) admitted to pre-op for heel cord lengthening. Child has cognitive and speech delays. Experiences absent seizures numerous times daily according to parent. The nurse is developing the plan of care for the child.
To provide atraumatic care for this child post-operatively, what will be a priority?
Pain assessments
Antibiotics
Occupational therapy
Wound care
Physical therapy
The Correct Answer is A
Assessing and managing pain is a crucial aspect of providing atraumatic care for any post-operative patient, including a child with spastic cerebral palsy. It is important to monitor and assess the child's pain levels regularly to ensure their comfort and
well-being. Pain can be particularly challenging to assess in a child with cognitive and speech delays, so the nurse should use appropriate pain assessment tools and also consider nonverbal cues, changes in behavior, and physiological indicators of pain.
While antibiotics may be prescribed if there is an infection present, it is not mentioned as a priority in this specific scenario. The focus is on providing atraumatic care post-operatively.
Occupational therapy, physical therapy, and wound care are all important components of the child's overall care, but they may not be the immediate priority post-operatively. The child's specific needs and surgical procedure will determine when these interventions are appropriate and can be incorporated into the plan of care as needed. However, addressing pain is of utmost importance in the immediate post-operative period.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is Choice C: “This must be a very difficult time for you.”
Choice A rationale: Telling the parent “You didn’t do anything wrong” might seem comforting, but it doesn’t address the parent’s feelings of guilt or responsibility.It’s important to remember that myelomeningocele is a birth defect that occurs when the spine and spinal cord do not develop completely1.It’s often not known why this happens, but it can be due to a combination of genetic and environmental factors2. Therefore, it’s not something the parent did or didn’t do.
Choice B rationale: Asking “Is there any particular reason why you think this is your fault?” could potentially lead to a constructive conversation. However, it might also make the parent feel defensive or as if they need to justify their feelings. It’s crucial to approach this situation with empathy and understanding, acknowledging the parent’s feelings without making them feel judged.
Choice C rationale: Saying “This must be a very difficult time for you” is the most helpful response because it acknowledges the parent’s feelings and offers empathy. It doesn’t place blame or make assumptions. Instead, it opens up a space for the parent to express their feelings and concerns.
Choice D rationale: While it’s true that surgery can help manage the condition1, saying “With surgery, your baby should have a full recovery” might be misleading.Myelomeningocele is the most severe form of spina bifida and can cause moderate to severe disabilities, such as muscle weakness, loss of bladder or bowel control, and/or paralysis2. Each case is unique, and while some children may have less severe symptoms, others may require lifelong management. It’s important to provide accurate and realistic information.
Remember, it’s essential to approach these conversations with empathy and understanding. Parents dealing with a diagnosis of myelomeningocele are likely experiencing a range of emotions, and they need support and accurate information.
Correct Answer is ["B","C","E"]
Explanation
A) Incorrect - Red blood cell count (RBC) is not directly relevant to the assessment of infection and its spread.
B) Correct- Core body temperature can be an indicator of systemic infection and needs to be reported to the healthcare provider for assessment and intervention.
C) Correct- Swollen lymph nodes in the groin suggest local and regional lymphatic involvement, indicating possible spread of infection. This finding needs further assessment and intervention.
D) Incorrect - The location of the initial intravenous (IV) site is not directly relevant to the assessment of infection and its spread.
E) Correct- An elevated white blood cell count (WBC) can indicate an inflammatory response to infection. This finding should be reported to the healthcare provider for further evaluation and treatment.
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