The nurse observes that the legs of a child with cerebral palsy cross involuntarily, and the child exhibits jerky movements with his arms as he tries to eat. The nurse recognizes that he has which type of cerebral palsy?

Ataxic

Athetoid

Mixed

Spastic

Answer and Explanation

The Correct Answer is D

A. Ataxic cerebral palsy involves problems with balance and coordination. Movements may appear clumsy or unsteady but do not typically include muscle stiffness or involuntary crossing of the legs.

B. Athetoid (or dyskinetic) cerebral palsy is characterized by slow, writhing involuntary movements, especially of the face, trunk, and limbs. The child described has more jerky than writhing movements.

C. Mixed cerebral palsy includes symptoms of more than one type (e.g., spastic and athetoid). Although this is possible, the specific signs described (scissoring legs and jerky arm movements) are classic for spastic type.

D. Spastic cerebral palsy is the most common form and is characterized by increased muscle tone (hypertonia), resulting in stiff muscles and awkward movements. Scissoring of the legs and jerky movements are hallmark signs.

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Correct Answer is B

Explanation

A. Inability to touch the nose with eyes closed is part of the finger-to-nose test, not the Romberg test.
B. A positive Romberg testis indicated when the patient sways or loses balancewhile standing with feet together and eyes closed. This suggests a problem with proprioception or the vestibular system.
C. Dizziness may occur during the test but does not constitute a positive resultunless accompanied by swaying or imbalance.
D. The patient being unable to keep eyes closedis not a criterion for a positive Romberg test. The test evaluates balance, not voluntary eye closure.

A. Child's heels are placed firmly against the foot of the bed. B. Head of bed is elevated 20 degrees. C. Ropes are on pulleys. D. Weights are hanging freely.

Correct Answer is A

Explanation

A. In Buck traction, the child’s heels should not be pressed against the foot of the bed, as this disrupts the traction forceand may lead to skin breakdown or impaired circulation. The body must remain in proper alignment, and the child should be positioned so that traction can pull effectively.
B. Elevating the head of the bed up to 20 degreesis acceptable to promote comfort and prevent respiratory complications without affecting traction.
C. Ropes must be aligned properly on pulleysto ensure smooth traction force. This is a correct observation.
D. Weights should hang freelyat all times to maintain consistent traction; this is the correct setup.

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The nurse observes that the legs of a child with cerebral palsy cross involuntarily, and the child exhibits jerky movements with his arms as he tries to eat. The nurse recognizes that he has which type of cerebral palsy?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which behavior causes the nurse to report a positive Romberg test?

Correct Answer is B

Explanation

On entering the room of a child in Buck traction, the nurse makes all of the following observations. Which observation requires a nursing intervention?

Correct Answer is A

Explanation

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