The nurse is planning care for a child with muscular dystrophy.
What is an appropriate nursing goal?

Choice A rationale

Providing a calm, structured environment with consistent routines helps children with ADHD regulate their behavior and attention. Predictable schedules and clear expectations reduce sensory overload and provide a framework for self-management, thereby promoting focus and minimizing disruptive behaviors by optimizing neurological processing.

Choice B rationale

Removing the child from the classroom as a primary intervention is counterproductive. While a brief cool-down period might sometimes be useful, consistent removal can isolate the child, disrupt their learning, and prevent them from developing coping mechanisms within the regular classroom setting, hindering social and academic integration.

Choice C rationale

Punishing a child with ADHD each time rules are broken is generally ineffective and can be detrimental. ADHD is a neurodevelopmental disorder affecting impulse control and attention; punishment alone does not address the underlying neurological differences. It can lead to increased anxiety, defiance, and a negative self-concept.

Choice D rationale

Recommending home schooling for a child with ADHD should not be the most appropriate first intervention. While home schooling can be an option for some families, it removes the child from valuable social learning experiences and peer interaction crucial for development. Classroom interventions and support should be exhausted first.

Choice A rationale

Notifying the healthcare provider immediately and requesting antibiotics is premature. Slight redness around pin sites without drainage or pain, and stable vital signs, does not immediately indicate a significant infection requiring systemic antibiotics. This initial finding warrants a thorough assessment and local care before escalating to medical intervention.

Choice B rationale

Removing crusting around pin sites can be detrimental. Crusting can serve as a protective barrier. Aggressive removal can introduce bacteria into the pin tract, increasing the risk of infection, or cause unnecessary pain and trauma to the delicate healing tissue. Gentle cleansing is preferred over forceful removal of adherent crusts.

Choice C rationale

Cleansing the pin sites using sterile saline and assessing for signs of infection is the best immediate action. Slight redness without drainage is often a normal inflammatory response to the foreign body and movement. Sterile saline effectively cleanses without irritating the tissue, and continued assessment helps monitor for evolving signs like increased redness, purulent drainage, or fever.

Choice D rationale

Documenting findings as normal and continuing routine assessments is insufficient. While slight redness can be normal, it still requires diligent monitoring and appropriate pin site care to prevent potential complications. Assuming normalcy without active intervention like cleansing could allow a minor irritation to progress to a more serious infection. .