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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: Lethargy and hypotonia are concerning symptoms that indicate a significant decrease in muscle tone and alertness, which can be associated with various medical conditions. However, they may not require immediate intervention compared to a critically low heart rate.

Choice B reason: Elastic skin turgor is generally a normal finding, indicating good hydration status and skin elasticity. It does not require urgent attention.

Choice C reason: An apical heart rate of 64 beats per minute is significantly low for a paediatric patient, indicating bradycardia. This requires immediate attention and intervention to ensure the patient's cardiovascular stability.

Choice D reason: A blood pressure of 100/54 mmHg is within a normal range for many paediatric patients and does not indicate an immediate emergency.

Choice E reason: A flat anterior fontanel is a normal finding in infants and does not require urgent intervention.

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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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the assessment findings of a paediatric patient. Which finding will the nurse prioritize?

Correct Answer is C

Explanation

The nurse is caring for an infant delivered one minute ago. The infant has no spontaneous respirations, no response to stimulus, is limp, pale, and has a heart rate of 99 beats per minute. How will the nurse document this infant's APGAR Score? Enter number only (no units).

Correct Answer is ["1"]

Explanation

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