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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.
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The nurse is preparing a staff education in-service session for a group of new graduate nurses who will be working in a long-term care facility for children; many of the children have cerebral palsy (CP). What statement should the nurse include in the training?
- A. Children with dyskinetic CP have a wide-based gait and repetitive movements.
- B. Children with spastic pyramidal CP have a positive Babinski sign and ankle clonus.
- C. Children with hemiplegia CP have mouth muscles and one lower limb affected.
- D. Children with ataxic CP have involvement of pharyngeal and oral muscles with dysarthria.
Correct Answer: B
Rationale: Spastic pyramidal CP is characterized by a positive Babinski sign and ankle clonus due to hypertonicity. Dyskinetic CP involves oral muscles and dysarthria, hemiplegia affects one side with upper limbs more impacted, and ataxic CP features a wide-based gait.
Gingivitis is a common problem in children with cerebral palsy (CP). What preventive measure should be included in the plan of care?
- A. High-carbohydrate diet
- B. Meticulous dental hygiene
- C. Minimum use of fluoride
- D. Avoidance of medications that contribute to gingivitis
Correct Answer: B
Rationale: Meticulous dental hygiene prevents gingivitis in CP, countering enamel defects, high-carbohydrate diets, and spasticity-related oral care challenges. Fluoride use is encouraged, and medications like phenytoin may require hygiene adjustments, not avoidance.
An adolescent with a spinal cord injury is admitted to a rehabilitation center. Her parents describe her as being angry, hostile, and uncooperative. The nurse should recognize that this is suggestive of which psychosocial state?
- A. Normal phase of adolescent development
- B. Severe depression that will require long-term counseling
- C. Normal response to her situation that can be redirected in a healthy way
- D. Denial response to her situation that makes rehabilitative efforts more difficult
Correct Answer: C
Rationale: Anger, hostility, and uncooperativeness in a spinal cord injury adolescent reflect a normal response to disrupted independence, which can be redirected positively during rehabilitation. This isn?t typical adolescent behavior, severe depression, or denial, but an adaptive phase.
What type of cerebral palsy (CP) is the most common type?
- A. Ataxic
- B. Spastic
- C. Dyskinetic
- D. Mixed type
Correct Answer: B
Rationale: Spastic CP, marked by initial hypotonia transitioning to hypertonicity, is the most common type. Ataxic, dyskinetic, and mixed types are less frequent, with spastic CP showing increased stretch reflexes and weakness.
The nurse should suspect a child has cerebral palsy (CP) if the parent says what?
- A. My 6-month-old baby is rolling from back to prone now.
- B. My 4-month-old doesnt lift his head when on his tummy.
- C. My 8-month-old can sit without support.
- D. My 10-month-old is not walking.
Correct Answer: B
Rationale: A 4-month-old not lifting their head when prone indicates a gross motor delay, a hallmark of CP, as this skill is expected by 0-3 months. Rolling at 6 months, sitting at 8 months, and not walking at 10 months are within normal developmental ranges.