The nurse is educating parents of a child with a cleft palate.
What should the nurse instruct the parents to report immediately?
Facial paralysis.
Ear infections.
Increased intracranial pressure.
Drooling.
The Correct Answer is C
Choice A rationale
While facial paralysis is a serious condition, it is not typically associated with a cleft palate.
Choice B rationale
Ear infections are a common complication of a cleft palate, but they are not typically a sign of an immediate, serious problem.
Choice C rationale
Increased intracranial pressure is not a common complication of a cleft palate, but it is a serious condition that requires immediate medical attention.
Choice D rationale
Drooling is common in children with a cleft palate and is not typically a sign of a serious problem.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
The FACES pain scale is typically used for children who are at least 3 years old. It requires the child to compare their pain to a series of faces ranging from smiling to crying.
Choice B rationale
The Word-Graphic Rating Scale is typically used for older children and adolescents who can read and understand the descriptive words associated with each level of pain.
Choice C rationale
The FLACC pain scale, which stands for Face, Legs, Activity, Cry, and Consolability, is appropriate for assessing pain in a 3-month-old infant. It is often used for children under 3 years old or those who are unable to verbally communicate their pain.
Choice D rationale
The Oucher pain scale is typically used for children aged 3 to 13 years. It includes a series of photographs of children’s faces and a numerical scale for older children.
Correct Answer is B
Explanation
Choice A rationale
Hypertension is not typically associated with spina bifida. While it can occur in any individual based on a variety of factors such as diet, lifestyle, and genetics, it is not a direct complication of spina bifida.
Choice B rationale
Urinary tract infections are a common complication in individuals with spina bifida. This is because many people with this condition often cannot control their bladder and bowel movements, which can lead to infections. The nerves that control the bladder and bowel are often damaged in spina bifida, leading to issues with these functions and increasing the risk of urinary tract infections.
Choice C rationale
Hearing loss is not typically a complication of spina bifida. While hearing loss can occur due to a variety of reasons such as age, exposure to loud noises, and certain illnesses, it is not directly related to spina bifida.
Choice D rationale
Type 1 diabetes is not a known complication of spina bifida. Diabetes is a condition that affects the body’s ability to regulate blood sugar levels and is not directly related to the neurological and physical issues caused by spina bifida.
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