Nokea
A 4-month-old with significant head lag meets the criteria for floppy infant syndrome. A diagnosis of progressive infantile spinal muscular atrophy (Werdnig-Hoffmann disease) is made. What should be included in the nursing care for this child?
- A. Infant stimulation program
- B. Stretching exercises to decrease contractures
- C. Limited physical contact to minimize seizures
- D. Encouraging parents to have additional children
Correct Answer: A
Rationale: An infant stimulation program with frequent position changes and sensory input is vital for Werdnig-Hoffmann disease to support development. Contractures are not a concern due to muscle atrophy, sensation is normal, and genetic counseling is needed, not encouragement for more children.
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A child, age 3 years, has cerebral palsy (CP) and is hospitalized for orthopedic surgery. His mother says he has difficulty swallowing and cannot hold a utensil to feed himself. He is slightly underweight for his height. What is the most appropriate nursing action related to feeding this child?
- A. Bottle or tube feed him a specialized formula until he gains sufficient weight.
- B. Stabilize his jaw with caregivers hand (either from a front or side position) to facilitate swallowing.
- C. Place him in a well-supported, semireclining position.
- D. Place him in a sitting position with his neck hyperextended to make use of gravity flow.
Correct Answer: B
Rationale: Stabilizing the jaw from the front or side improves swallowing control in CP, addressing compromised jaw function. Bottle or tube feeding doesn?t address jaw issues, and semireclining or hyperextended positions increase aspiration risk.
The nurse is caring for a family whose infant was just born with anencephaly. What is the most important nursing intervention?
- A. Implement measures to facilitate the attachment process.
- B. Help the family cope with the birth of an infant with a fatal defect.
- C. Prepare the family for extensive surgical procedures that will be needed.
- D. Provide emotional support so the family can adjust to the birth of an infant with problems.
Correct Answer: B
Rationale: Anencephaly, a fatal neural tube defect, requires nursing support to help families cope with grief and provide comfort measures for the infant, who may survive briefly. Attachment is encouraged but secondary, no surgical options exist, and general support is less specific.
The parents of an infant with cerebral palsy (CP) ask the nurse if their child will have cognitive impairment. The nurses response should be based on which knowledge?
- A. Affected children have some degree of cognitive impairment.
- B. Around 20% of affected children have normal intelligence.
- C. About 45% of affected children have normal intelligence.
- D. Cognitive impairment is expected if motor and sensory deficits are severe.
Correct Answer: C
Rationale: Approximately 40% to 50% of children with CP have normal intelligence, with a wide range of cognitive outcomes. Severe physical impairment does not necessarily correlate with cognitive deficits, and many have minimal intellectual compromise.
An 8-year-old girl with moderate cerebral palsy (CP) recently began joining a regular classroom for part of the day. Her mother asks the school nurse about joining the after-school Girl Scout troop. The nurses response should be based on which knowledge?
- A. Most activities such as Girl Scouts cannot be adapted for children with CP.
- B. After-school activities usually result in extreme fatigue for children with CP.
- C. Trying to participate in activities such as Girl Scouts leads to lowered self-esteem in children with CP.
- D. Recreational activities often provide children with CP with opportunities for socialization and recreation.
Correct Answer: D
Rationale: Recreational activities like Girl Scouts enhance socialization, recreation, and self-esteem in children with CP, with adaptations available. They don?t typically cause extreme fatigue or lower self-esteem, and most activities can be modified.
A 14-year-old girl is in the intensive care unit after a spinal cord injury 2 days ago. What nursing intervention is a priority for this child?
- A. Minimizing environmental stimuli
- B. Administering immunoglobulin
- C. Monitoring and maintaining systemic blood pressure
- D. Discussing long-term care issues with the family
Correct Answer: C
Rationale: Monitoring and maintaining blood pressure is critical in spinal cord injury due to physiologic lability and risks like autonomic dysreflexia. Stimuli minimization and immunoglobulin aren?t needed, and long-term care discussions are premature during acute stabilization.