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The nurse is caring for a 4-year-old child with cerebral palsy (CP). The child, developmentally, is at an infant stage. Appropriate developmental stimulation for this child should be what?
- A. Playing pat-a-cake with the child
- B. None so the child does not become overstimulated
- C. Putting a colorful mobile with music on the bed
- D. Giving the child a coloring book and crayons
Correct Answer: C
Rationale: A colorful mobile with music provides sensory stimulation appropriate for an infant developmental stage, supporting sensory input needs in CP. Pat-a-cake and coloring are too advanced, and avoiding stimulation neglects developmental needs.
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An 8-year-old child is hospitalized with infectious polyneuritis (Guillain-Barré syndrome [GBS]). When explaining this disease process to the parents, what should the nurse consider?
- A. Paralysis is progressive with little hope for recovery.
- B. Disease is inherited as an autosomal, sex-linked, recessive gene.
- C. Disease results from an apparently toxic reaction to certain medications.
- D. Muscle strength slowly returns, and most children recover.
Correct Answer: D
Rationale: GBS involves progressive paralysis with recovery of muscle strength starting within 2-3 weeks, with most children regaining full strength, especially younger ones. It?s immune-mediated, not inherited or medication-induced, and has a good prognosis.
What is a major goal of therapy for children with cerebral palsy (CP)?
- A. Cure the underlying defect causing the disorder.
- B. Reverse the degenerative processes that have occurred.
- C. Prevent the spread to individuals in close contact with the child.
- D. Recognize the disorder early and promote optimum development.
Correct Answer: D
Rationale: Early recognition and promoting optimal development are key CP therapy goals, maximizing potential within physical limits. CP is permanent, not curable or reversible, and is not contagious.
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.
What is the most common cause of cerebral palsy (CP)?
- A. Central nervous system (CNS) diseases
- B. Birth asphyxia
- C. Cerebral trauma
- D. Neonatal encephalopathy
Correct Answer: D
Rationale: Neonatal encephalopathy, often from unknown prenatal causes, is implicated in about 80% of CP cases, particularly in term and preterm infants. CNS diseases, birth asphyxia, and cerebral trauma contribute but are less common causes.
An adolescent has just been brought to the emergency department with a spinal cord injury and paralysis from a diving accident. The parents keep asking the nurse, How bad is it? The nurses response should be based on which knowledge?
- A. Families adjust better to life-threatening injuries when information is given over time.
- B. Immediate loss of function is indicative of the long-term consequences of the injury.
- C. Extent and severity of damage cannot be determined for several weeks or even months.
- D. Numerous diagnostic tests will be done immediately to determine extent and severity of damage.
Correct Answer: C
Rationale: Spinal cord injury extent and severity are unclear initially due to physiologic responses, with improvement possible over weeks or months. Immediate loss doesn?t predict long-term outcomes, and while tests are done, prognosis requires time. Gradual information helps, but extent is the key issue.