A toddler has recently been diagnosed with cerebral palsy. Which of the following information should the nurse provide to the parents? Select one that doesn't apply.
- A. Regular developmental screening is important to avoid secondary developmental delays.
- B. Cerebral palsy is caused by injury to the upper motor neurons and results in motor dysfunction, as well as possible ocular and speech difficulties.
- C. Developmental milestones may be slightly delayed but usually will require no additional intervention.
- D. Parent support groups are helpful for sharing strategies and managing health care issues.
Correct Answer: C
Rationale: The correct answer is 'Developmental milestones may be slightly delayed but usually will require no additional intervention.' This statement is incorrect as delayed developmental milestones in a child with cerebral palsy require interventions and constant follow-ups. Developmental monitoring is essential to track a child's growth and development over time. If any concerns are raised during monitoring, a developmental screening test should be conducted promptly to address any developmental delays or issues. Regular interventions, therapies, and support are crucial to optimize the child's development and well-being. Therefore, it is important for parents to be aware that additional interventions may be necessary to support their child's development.
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A nurse is providing dismissal instructions for a child who was admitted for rotavirus. Which of the following statements by the parent indicates the need for further teaching?
- A. I'll start giving him his antibiotics as soon as we get home.
- B. I will call the physician if he becomes dizzy or overly fussy.
- C. He will need to wash his hands a lot to keep this from spreading.
- D. I'll watch to see when he stops having diarrhea stools.
Correct Answer: A
Rationale: The correct answer is 'I'll start giving him his antibiotics as soon as we get home.' Rotavirus is a viral illness, and antibiotics are ineffective for its treatment. The parent's statement indicates a need for further teaching as antibiotics are not appropriate for treating rotavirus. Option B is correct as it demonstrates the parent's understanding of when to contact the physician for concerning symptoms. Option C is a correct statement regarding infection control practices. Option D is also correct as monitoring diarrhea stools is essential to track recovery from rotavirus.
During an adolescent examination, the nurse asks a 13-year-old female to bend forward at the waist with arms hanging freely. Which of the following assessments is the nurse most likely conducting?
- A. Spinal flexibility
- B. Leg length disparity
- C. Hypostatic blood pressure
- D. Scoliosis
Correct Answer: D
Rationale: The correct answer is scoliosis. During the assessment for scoliosis, the nurse asks the adolescent to bend forward at the waist with arms hanging freely to observe for any lateral deviation of the spine, uneven rib levels, or asymmetry. This assessment is a routine part of an adolescent examination, especially in females, as scoliosis is more common in this population. Choices A, B, and C are incorrect. Spinal flexibility is usually assessed through different maneuvers, leg length disparity is evaluated by measuring the length of the legs, and hypostatic blood pressure refers to a decrease in blood pressure due to immobility.
Which of the following is an example of intragroup conflict?
- A. A nurse writes a grant for a non-profit organization to raise money for advertising
- B. Members of a multidisciplinary team cannot agree on the best course of action for a client
- C. A client does not receive his medication on time because the nurse was on break
- D. A nurse feels frustrated that her employer does not provide on-site child care
Correct Answer: B
Rationale: Intragroup conflict refers to disagreements within a group. The correct answer, 'Members of a multidisciplinary team cannot agree on the best course of action for a client,' exemplifies this type of conflict well. In this scenario, professionals within the same team are unable to reach a consensus on how to proceed with client care. Choices A, C, and D do not reflect intragroup conflict. Writing a grant for a non-profit organization, a client not receiving medication due to a nurse's break, and a nurse feeling frustrated about the lack of on-site child care do not involve conflicts within a group of professionals.
If you are caring for a patient of the Hindu culture, what may you anticipate regarding visitors?
- A. Limited visitors, respectful of privacy
- B. Family members only
- C. Large number of visitors/community support
- D. None of the above
Correct Answer: C
Rationale: In Hindu culture, there is a strong sense of community and support. It is common for a patient to receive a large number of visitors, indicative of the community coming together to provide emotional and practical support. This support network is crucial for the patient's well-being and healing process. Option A, limited visitors, is incorrect as the Hindu culture values community involvement. Option B, family members only, is incorrect as the support network extends beyond just family. Option D, none of the above, is incorrect as the Hindu culture typically involves community support and a significant number of visitors.
A patient with peripheral vascular disease is receiving discharge instructions. Which of the following information should be included?
- A. Walk barefoot whenever possible.
- B. Use a heating pad to keep feet warm.
- C. Avoid crossing the legs.
- D. Use antibacterial ointment to treat skin lesions prone to infection.
Correct Answer: C
Rationale: Patients with peripheral vascular disease should be advised to avoid crossing their legs as this can impede blood flow. Peripheral vascular disease, also known as arteriosclerosis obliterans, is primarily caused by atherosclerosis. Atherosclerosis results in the gradual progression of arterial occlusion due to the formation of atheromas. Crossed legs can further restrict blood flow, exacerbating the condition. Walking barefoot should be discouraged to prevent potential injuries to the feet. Using a heating pad can lead to burns and should be avoided to prevent thermal injuries. While using antibacterial ointment for skin lesions may be beneficial, it is not the priority instruction for patients with peripheral vascular disease.
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