Nokea
The parents of a child with spastic cerebral palsy (CP) state that their child seems to have significant pain. In addition to systemic pharmacologic management, the nurse includes which teaching?
- A. Patterning
- B. Positions to reduce spasticity
- C. Stretching exercises after meals
- D. Topical analgesics for muscle spasms
Correct Answer: B
Rationale: Teaching positions to reduce spasticity, such as specific sitting or lying postures, helps manage pain in spastic CP. Patterning is ineffective, stretching requires prior analgesia, and topical analgesics are not effective for CP spasms.
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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.
Spastic cerebral palsy (CP) is characterized by which clinical manifestations?
- A. Athetosis, dystonic movements
- B. Tremors, lack of active movement
- C. Hypertonicity; poor control of posture, balance, and coordinated motion
- D. Wide-based gait; poor performance of rapid, repetitive movements
Correct Answer: C
Rationale: Spastic CP features hypertonicity and poor posture, balance, and coordination control due to increased muscle tone and stretch reflexes. Athetosis and dystonia characterize dyskinetic CP, tremors suggest other disorders, and wide-based gait is typical of ataxic CP.
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.
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.
What statement is most accurate in describing tetanus?
- A. Inflammatory disease that causes extreme, localized muscle spasm.
- B. Disease affecting the salivary gland with resultant stiffness of the jaw.
- C. Acute infectious disease caused by an exotoxin produced by an anaerobic spore-forming, gram-positive bacillus.
- D. Acute infection that causes meningeal inflammation resulting in symptoms of generalized muscle spasm.
Correct Answer: C
Rationale: Tetanus, caused by Clostridium tetani?s exotoxins, affects the central nervous system, causing muscle stiffness and spasms, starting with the jaw (lockjaw). It?s not inflammatory, doesn?t affect salivary glands, and isn?t caused by meningeal inflammation.