The nurse is caring for a 4-year-old with cerebral palsy on an inpatient unit who is struggling to eat with regular utensils. What intervention will the nurse include in the plan of care?
Call the provider to request an enteral tube.
Provide large, padded utensils.
Have the parents feed the child.
Refer the patient to the nutritionist.
The Correct Answer is B
Choice A reason: Requesting an enteral tube is not necessary unless the child is unable to eat orally at all. The goal is to support the child's ability to eat independently, if possible.
Choice B reason: Providing large, padded utensils can help a child with cerebral palsy improve their ability to eat independently. Adaptive utensils are designed to accommodate the motor challenges that children with cerebral palsy may face, making it easier for them to grasp and use the utensils.
Choice C reason: While having the parents feed the child can be a short-term solution, it does not promote independence. The focus should be on finding ways to support the child's ability to eat on their own.
Choice D reason: Referring the patient to a nutritionist can be helpful for overall dietary management, but it does not directly address the immediate issue of the child's difficulty with using regular utensils. Adaptive utensils are a more direct solution to this problem.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Haemophilia patients often require Factor VIII replacement therapy before procedures such as dental cleanings to prevent bleeding. The statement that the child does not need Factor VIII before a dental cleaning indicates a misunderstanding of the need for prophylactic treatment.
Choice B reason: Aspirin is contraindicated for children with haemophilia as it can inhibit platelet function and increase the risk of bleeding. The statement that it is okay to use aspirin reflects a lack of understanding of the appropriate pain management for haemophilia.
Choice C reason: While it is important for children with haemophilia to stay active, certain high-impact or contact sports may increase the risk of bleeding and should be avoided. The statement that there are no limitations on the type of activities indicates a lack of awareness about the need to choose safe activities.
Choice D reason: Swimming is a low-impact activity that is generally safe and beneficial for children with haemophilia. It promotes cardiovascular fitness and muscle strength without putting undue stress on the joints or increasing the risk of bleeding. This statement demonstrates an understanding of appropriate activity choices for a child with haemophilia.
Correct Answer is ["1"]
Explanation
The APGAR score assesses five criteria: Appearance (skin colour), Pulse (heart rate), Grimace (reflex irritability), Activity (muscle tone), and Respiration (breathing effort). Each criterion is scored from 0 to 2, with a maximum total score of 10.
- Appearance: The infant is pale, which scores 0.
- Pulse: The heart rate is 99 beats per minute, which scores 1 (as it is below 100).
- Grimace: No response to stimulus, which scores 0.
- Activity: The infant is limp, which scores 0.
- Respiration: No spontaneous respirations, which scores 0.
Summing these scores gives a total APGAR score of 1.
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