Mod 25-3 Cerebral Palsy
The parents of a 7-year-old patient with cerebral palsy (CP) ask for strategies to help with mealtime for their child. Which statement should the nurse provide? "Provide soft foods with the use of large, padded utensils." "Provide a liquid diet only." "Provide foods that require chewing to prevent aspiration." "Continue feeding your child for nutrition purposes."
"Provide soft foods with the use of large, padded utensils." Problems with swallowing, sucking, chewing, and movements in the mouth and jaw also cause nutritional challenges. Give the child soft foods in small amounts. Utensils with large, padded handles may be easier for the child to use. Liquids only can be an aspiration risk, as well as possibly not provide adequate nutrition. The child should always be encouraged to function independently.
A 9-year-old patient with cerebral palsy (CP) is being evaluated for a procedure that will assist with improving ambulation. For which procedure should the nurse prepare teaching? Achilles tendon lengthening Selective dorsal rhizotomy Hamstring release Joint stabilization
Achilles tendon lengthening Achilles tendon lengthening is most frequently done to improve ambulation that is impaired due to contractures of the tendon. This can assist with the ability to walk flat-footed, which can allow or improve ambulation. Selective dorsal rhizotomy is done to reduce spasticity. Hamstring lengthening will improve contractures and joint deformity. Joint stabilization can help provide support to joints that are damaged due to contractures or arthritis.
The nurse is discussing surgery treatment options with the parents of a child with cerebral palsy (CP). Which surgical intervention should the nurse review for applicability prior to discussing with the parents? Achilles tendon shortening Surgically implanted intrathecal pump Releasing the hamstrings Dorsal rhizotomy
Achilles tendon shortening Achilles tendon lengthening, not shortening, is a surgical intervention that is used to treat CP. Other surgical treatments include surgical implantation of an intrathecal pump, releasing the hamstrings, and dorsal rhizotomy.
The parents of a 5-year-old patient with mixed cerebral palsy (CP) ask why a baclofen pump is scheduled to be surgically implanted in the child. Which explanation should the nurse give about the purpose of this medication pump? It controls muscle spasms. It increases ankle range of motion. It allows flat-footed walking. It prevents infections.
It controls muscle spasms. Implantation of a baclofen pump allows continuous delivery of the drug baclofen, which improves muscle spasms. The surgical treatment of Achilles tendon lengthening is used to increase ankle range of motion and to allow the child to walk flat-footed. Intrathecal pump implantation actually increases the risk of infection and must be carefully monitored. Baclofen is not being provided to the patient to prevent infections.
A 22-year-old patient with cerebral palsy (CP) is experiencing chronic pain. Which reason should the nurse identify that explains the most common cause of chronic pain in adults with this health problem? Muscle contractions Skin breakdown Skeletal deformities Brain lesions
Muscle contractions Muscle contractions place the body in a continuous state of stress. The pain that results from this increases with age. Skin breakdown may occur in those who have urinary or bowel incontinence, but this is not the most common cause of pain. Skeletal deformities can result in positional discomfort but are not the leading cause of pain. Brain lesions are not a common cause of pain in those with CP.
The mother of an 18-month-old child is concerned about the child not meeting developmental milestones and wants the child tested for cerebral palsy. Which diagnostic approach should the nurse explain to this mother? Observation of symptoms and ruling out other disorders CT scan Laboratory test for certain proteins Urinalysis
Observation of symptoms and ruling out other disorders There is no specific diagnostic test for CP. Diagnosis is usually made by observation of symptoms and ruling out other causes of manifestations. CT scan may be used to identify other organic brain diseases that may be causing certain symptoms but is not used to specifically diagnose CP. Laboratory testing for proteins and results of urinalysis are not helpful in diagnosing CP.
The nurse is visiting a 17-year-old adolescent with cerebral palsy (CP). Which intervention should the nurse recommend to assist this patient with physical mobility when attending college in a few months? Obtaining a customized wheelchair Learning American sign language Using adaptive utensils Receiving therapeutic massages every week
Obtaining a customized wheelchair Adaptive and assistive technology to promote mobility includes the use of a customized wheelchair. There is no evidence that the patient does not speak or hear. Adaptive utensils ensure adequate nutritional intake. Receiving therapeutic massages would reduce spasticity and encourage muscle relaxation.
The nurse is caring for a child with cerebral palsy. Which intervention should the nurse use to support this patient's nutritional status? Provide small amounts of food at a time. Use utensils with small, padded, adaptive handles. Restrict fluid intake. Provide adequate protein.
Provide small amounts of food at a time. Small amounts of food should be given to a child with CP because of problems with chewing and swallowing. Utensils with large, not small, padded, adaptive handles should be provided. There is no need to restrict this child's fluid. All nutrients are important for this patient.
Which conditions most frequently shorten the life of adults with cerebral palsy (CP)? Respiratory disorders and seizures Incontinence and skin breakdown Muscle atrophy and brain tumors Arthritis and contractures
Respiratory disorders and seizures Respiratory disorders and seizures can shorten the life of adults with CP. Incontinence and skin breakdown can lead to infection and complications, but these are not as life-limiting as respiratory and seizure disorders. Muscle atrophy can lead to complications, and brain tumors are not necessarily prone to occur in those with CP. Arthritis and contractures can lead to further mobility but are not directly life limiting.
A 7-year-old girl with dyskinetic cerebral palsy (CP) uses either a stroller or wheelchair for mobility since birth. Which assessment should the nurse consider the priority? Skin integrity and body alignment Height and weight Nutrition status and bowel function Swallowing difficulty
Skin integrity and body alignment Skin integrity and good body alignment are essential for a child with CP who is in a wheelchair. Pillows, towels, and bolsters may be needed for positioning or to take pressure off reddened areas of skin. Height and weight must be assessed for every child, as should nutrition status and bowel habits. Assessment for swallowing difficulty is used to detect clinical manifestations that may indicate that a child has CP.
The nurse is preparing teaching material about cerebral palsy (CP). Which nonpharmacologic therapy should the nurse include in this teaching? (Select all that apply.) A. Special education B. Oxygen therapy C. Occupational therapy D. Physical therapy E. Speech therapy
A. Special education C. Occupational therapy D. Physical therapy E. Speech therapy Rationale: Clinical therapy is used for clients who have CP to help them develop their maximum level of independence. To improve motor function and ability, referrals are made for physical, occupational, and speech therapy, as well as special education. Oxygen therapy is not necessary for all individuals with CP, only those with breathing disorders who require it.
A pregnant patient is scheduled for an ultrasound to attempt to diagnose the possibility of cerebral palsy (CP). Which statement should the nurse use to explain to the patient how this test is used to identify the possibility of CP? "An ultrasound can detect abnormalities of the brain that can increase the likelihood of the presence of CP." "An ultrasound can detect specific deformities and developmental disorders that are associated with CP." "An ultrasound can determine the position of the fetus in the uterus, which can identify any possible abnormality leading to CP." "An ultrasound can positively detect CP by measuring the size of the brain."
"An ultrasound can detect abnormalities of the brain that can increase the likelihood of the presence of CP." Neonatal brain abnormalities, such as intraventricular hemorrhage, can contribute to the development of CP. An ultrasound can help detect these abnormalities prior to birth. An ultrasound can detect birth defects and abnormalities, but these are not necessarily associated with CP. Fetal position is not associated with CP, although malpositioned infants, such as breech presentation, can increase risk of difficult delivery and brain injury. CP is not identified by the size of the brain.
The parent of a child with cerebral palsy (CP) ask the nurse, "What is the purpose of these braces?" Which response by the nurse is correct? "Braces help with mobility and provide stabilization." "Braces will protect your child from broken bones." "Braces will help promote flexibility." "Braces will help strengthen muscles."
"Braces help with mobility and provide stabilization." Braces for a patient with CP serve the purpose of providing stability and, in turn, promoting mobility. Braces do not provide protection; it is still possible for a patient to break a bone while wearing braces. Therapeutic massage, not braces, helps strengthen muscles and promote flexibility.
The nurse is obtaining a health history from the parents of a child with cerebral palsy (CP). Which question should the nurse use to determine whether the child's brain insult happened after birth? "Were there any accidents before age 3?" "Was the mother older than 40 years when the child was born?" "Was the child born prematurely?" "Was the child born subsequent to the fourth child?"
"Were there any accidents before age 3?" Asking about maternal age at birth, prematurity, and birth order all assess possible prenatal causes of CP. Asking about accidents before age 3 can help determine whether the child's brain insult happened after birth.
An 18-month-old client is suspected of having cerebral palsy (CP). Which test should the nurse expect to be prescribed to help diagnose this client? (Select all that apply.) A. CT scan B. Electrocardiographic studies C. PET scan D. MRI E. Laboratory studies of protein levels in the bloodstream
A. CT scan C. PET scan D. MRI Rationale: There is no specific diagnostic test for CP, but MRI, CT scan, and PET scan can be helpful in eliminating other organic brain disease, such as tumors or developmental issues. Electrocardiographic studies and laboratory studies are not used to diagnose CP.
The parents of a child with cerebral palsy (CP) are concerned about possible future health problems. The nurse knows the client is at risk for which complication? (Select all that apply.) A. Urinary incontinence B. Decreased cognitive ability C. Hypotension D. Depression E. Premature aging
A. Urinary incontinence B. Decreased cognitive ability D. Depression E. Premature aging Rationale: The client with CP is at risk for multiple comorbidities to include depression, decreased cognitive ability, urinary and bowel incontinence, and premature aging. The client with CP is at risk for developing hypertension, not hypotension.
The parents of a child with cerebral palsy (CP) ask if there are any medications available to help control the child's symptoms. Which type of medication should the nurse discuss with the parents? (Select all that apply.) A. Antidepressants B. Botulinum toxin C. Baclofen D. Benzodiazepines E. Muscle relaxants
B. Botulinum toxin C. Baclofen D. Benzodiazepines E. Muscle relaxants Rationale: Medications that are used to control seizures and spasms include skeletal muscle relaxants, baclofen, benzodiazepines, and botulinum toxin. Antidepressants are not used to manage the symptoms of CP.
An infant, who is not meeting developmental goals and is displaying spastic motion, will be evaluated for possible cerebral palsy (CP). Which component of the infant's medical history should the nurse identify as the greatest risk factor for the health problem? Born premature at 29 weeks of gestation Family history of CP The mother having had numerous respiratory infections during pregnancy No prenatal care during pregnancy
Born premature at 29 weeks of gestation Approximately 35% of CP cases occur in individuals with a history of preterm birth. Studies have found the earlier in gestational age the infant is born, the greater the likelihood the infant will have CP. A family history is not considered a strong factor, although studies show there may be a genetic component. Exposure to viruses while in utero increases the risk, but this is not as great a risk as preterm birth. Lack of prenatal care may increase risk since this is a factor in not identifying a number of conditions, but preterm birth is the greatest risk factor.
A term newborn who contracted an infection in utero may have spastic cerebral palsy (CP) caused by a brain insult from the infection. Which area of the brain should the nurse explain was affected when talking to the patient's parents? Cerebral cortex Cerebellum Multiple areas Basal ganglia
Cerebral cortex Spastic CP is generally attributable to a brain insult in the cerebral cortex. Ataxic CP is generally attributable to a brain insult in the cerebellum. Mixed CP is generally attributable to multiple injury sites. Dyskinetic CP is generally attributable to a brain insult in the basal ganglia.
The nurse is conducting an in-service about cerebral palsy (CP). Which lifespan considerations should the nurse include? Comorbidities often shorten the lifespan of those with CP. Premature aging is uncommon in CP. Most patients with CP are severely disabled and dependent. Bowel and bladder incontinence is uncommon in CP.
Comorbidities often shorten the lifespan of those with CP. Seizures and respiratory disorders are examples of comorbidities that shorten the lifespan of patients with CP. Premature aging is often seen in patients with CP due to the continual state of stress on the body. Many children with CP grow up to lead full, independent lives and have families. Those with CP are prone to bowel and bladder incontinence, which can hinder their quality of life.
The nurse is evaluating care provided to a 9-year-old patient with cerebral palsy (CP). Which patient outcome should indicate to the nurse that the patient has achieved a developmental milestone? The patient has joined the Girl Scouts. The patient is able to feed themselves. The patient's parents administer medications appropriately. The patient returns for follow-up doctor's appointments as scheduled.
The patient has joined the Girl Scouts. Joining age-appropriate group activities indicates that the patient is achieving an age-related developmental milestone. The patient should be able to self-feed by this age. Following a prescribed medication regimen and having routine medical evaluations does not measure the success of nursing care.
The caregiver of a 30-year-old client with cerebral palsy (CP) asks if there are any changes in health that might develop. Which response should the nurse make? A. "It is impossible to predict which health changes he will experience." B. "He will gradually become more and more independent as the spasticity in the muscles diminishes." C. "He will likely develop signs of premature aging as a result of constant stress on the body." D. "People with CP don't often live past 30."
C. "He will likely develop signs of premature aging as a result of constant stress on the body." Rationale: In clients with CP, constant stress on the body can cause premature aging. Conditions such as hypertension, osteoarthritis, and atherosclerosis often develop before age 40. Numerous clients with CP do live past age 30, and this is increasing as symptom management becomes more effective. Independence usually does not increase as a result of aging, but the manifestations may become more severe or result in further complications.
1-year-old child is being evaluated for cerebral palsy (CP). Which finding should the nurse least expect to assess in this client? A. Normal muscle tone in all extremities B. Developmental delay C. Arching of the back D. Strabismus
A. Normal muscle tone in all extremities Rationale: Infants and children with CP do not exhibit normal muscle tone. Infants with cerebral palsy often exhibit arching of the back. Children with CP often experience delay in reaching developmental milestones. Strabismus is seen in children with CP.
A 6-year-old child with cerebral palsy (CP) new to a school district is experiencing severe rigidity and spasticity. What should the school nurse say to the parents? A. "Discourage the use of a computer." B. "What exercises can we do during school to help with the rigidity?" C. "Look into special schools for the handicapped." D. "Offer only low-carbohydrate, low-calorie foods to the child."
B. "What exercises can we do during school to help with the rigidity?" Rationale: The child with CP most likely has been evaluated and treated by a physical therapist who developed a plan for tendon stretching and range-of-motion exercises to decrease the rigidity and spasticity. This plan should be shared with the school nurse. Most school districts do not require that children with physical disabilities such as those associated with CP attend alternative schools. Children with CP require high-calorie foods because of feeding difficulties associated with spasticity and hypotonia. Computers are encouraged to promote communication
correct, Study Plan 25-3.1.2 A child is newly diagnosed with cerebral palsy (CP). For which type of cerebral palsy should the nurse most likely plan care? A. Ataxic cerebral palsy B. Dyskinetic cerebral palsy C. Spastic cerebral palsy D. Mixed cerebral palsy
C. Spastic cerebral palsy Rationale: About 80% of all cases of CP are classified as spastic. The other types of cerebral palsy are less common.
The nurse is teaching the parents of a child with cerebral palsy (CP) about appropriate therapies that can help the child's mobility status. Which statement by the parents should indicate to the nurse that teaching was effective? "Braces will help maintain our child's skeletal alignment." "We should not use splints on our child's limbs." "Serial casting is not recommended for treatment anymore." "Nothing will help with involuntary movements."
"Braces will help maintain our child's skeletal alignment." Braces and splints, serial casting, and positioning devices such as prone wedges, standers, and side-lyers are used to prevent contractures and promote range of motion, skeletal alignment, stability, and control of involuntary movements.
The nurse is giving an overview of cerebral palsy (CP) to a group of new nurses. Which statement should the nurse include in the teaching? "Not all patients with CP have an intellectual disability." "CP is a progressive disease that is inherited." "CP is identified during the prenatal period." "The pathogenesis of CP is the same in most cases."
"Not all patients with CP have an intellectual disability." CP may or may not include an intellectual disability. CP is not progressive and not inherited; however, genetic mutations have been found recently in some patients with CP. Some cases of CP occur after birth and not during the prenatal period, and the pathogenesis varies from patient to patient. Pathogens, toxins, trauma, hypoxia, and genetic mutations can all lead to CP.
The nurse is caring for a client with cerebral palsy (CP) who wears bilateral leg braces and requires full assistance to mobilize. For which condition is the client at risk? (Select all that apply.) A. Increased dental caries B. Atherosclerosis C. Pressure injuries D. Muscle contractures E. Fatigue
C. Pressure injuries D. Muscle contractures E. Fatigue Rationale: The nurse should protect bony prominences and assess regularly for redness and skin breakdown under the braces. The client's inability to change positions independently also places her at risk for pressure wounds and muscle contractures. Fatigue results from the extended energy needed to work against the muscle contractures. Atherosclerosis is a severe problem with CP that is associated with aging but is not caused by the leg braces or immobility. Dental caries are also unrelated to the braces or physical dependence.
A 9-month-old child is diagnosed with spastic cerebral palsy (CP). Which clinical manifestation should the nurse expect to assess in this patient? Hypertonia and rigidity Hemiplegia and hypotonia Bizarre twitching movements Tremors and exaggerated posturing
Hypertonia and rigidity Hypertonia in infancy and muscle rigidity are seen in spastic cerebral palsy. Hypotonia is seen in dyskinetic CP caused by an extrapyramidal injury. Tremors and exaggerated posturing are seen in dyskinetic CP. Bizarre twitching movements are seen in dyskinetic CP caused by an extrapyramidal, basal ganglia injury.
The nurse is reviewing the care of a patient with cerebral palsy (CP) with a new nurse. Which medication should the nurse emphasize would be effective in minimizing gastrointestinal side effects of CP? Ranitidine Baclofen Dantrolene Botulinum toxin
Ranitidine Ranitidine or cimetidine are used to minimize gastrointestinal side effects. Medications used to control spasms include skeletal muscle relaxants, baclofen, and benzodiazepines. Botulinum toxin has been used to decrease spasticity.
A 6-year-old patient with cerebral palsy (CP) is being fed by their mother. The nurse notices that the patient is reaching for the spoon and attempting to self-feed. Which is the most appropriate intervention? Providing large, padded utensils and encouraging self-feeding Assisting the mother by holding the child's hands to prevent food from spilling Encouraging the mother to keep trying, because it is not likely that the child will be able to self-feed Discussing possible tube feeding with the healthcare provider
Providing large, padded utensils and encouraging self-feeding Specially designed utensils and encouraging self-feeding promote independence and can improve coordination. Large, padded utensils are easy to grasp and should be provided to promote self-feeding. Restraining a child who is attempting to self-feed is not appropriate and should never be done. The mother should keep trying but with the correct utensils. Tube feeding is not usually indicated if the child is able to eat.
3-year-old patient with cerebral palsy (CP) has begun having seizures. Which recommendation should the nurse make to enhance this patient's safety? Wear a helmet. Ensure adequate lighting in walkways. Use specialized safety belts when seated. Apply leg braces.
Wear a helmet. A child with CP who has seizures is at risk for a head injury from falling or trauma to the head during a seizure. A helmet would protect the child's head. Keeping hallways adequately lit is more appropriate as a precaution for older children. Seat belts are not needed every time the patient sits. Braces may be effective in preventing contractures but are not beneficial in preventing injury in children who have seizures.
Study Plan 25-3.2.2 A 7-year-old client with cerebral palsy (CP) is learning to self-feed. Which action should the nurse encourage to promote independence and success with self-feeding? A. Restricting attempts at self-feeding to 5 minutes B. Assisting the parents with total feeding C. Reassuring the child that having to be fed is nothing to be ashamed of D. Providing large, padded eating utensils
D. Providing large, padded eating utensils Rationale: Providing large, padded utensils makes self-feeding easier and facilitates success with this endeavor. Children with CP should be encouraged to do as much as they can for themselves. Insisting on total feeding or not allowing prolonged periods of time to practice self-feeding does not help encourage independence.
The parents of a 3-year-old child with cerebral palsy (CP) do not wish to begin any physical therapy or use braces or positioning devices until the child is older. Which response should the nurse make to the parents? "The earlier the intervention is started, the better the long-term result to optimize independence." "You may want to wait until walking occurs." "You shouldn't wait because that could make the condition much worse." "It's up to you. It really doesn't matter when therapy is started."
"The earlier the intervention is started, the better the long-term result to optimize independence." The earlier therapies and interventions are started in those with CP, the more effective they are and the more they will enhance independence. Parents should be encouraged to begin interventions as soon as possible and not wait for milestones such as walking. Waiting will not result in a worsened condition but will not provide the benefit of early therapy.
A family caregiver asks why a 40-year-old patient with cerebral palsy (CP) developed hypertension at such a young age. Which response should the nurse make? "The effects of constant stress on the body caused by CP leads to the development of conditions earlier in life." "There may be a family history of hypertension that you did not know about." "People with CP are at increased risk of developing hypertension and other cardiovascular problems due to immobility." "You may want to reduce salt and fat in his diet. He obviously has not been eating a healthy diet."
"The effects of constant stress on the body caused by CP leads to the development of conditions earlier in life." Conditions such as hypertension and atherosclerotic heart disease occur frequently at an early age in those with CP as a result of the constant stress on the body leading to premature aging. A family history may or may not be relevant in the presence of CP. Immobility can lead to numerous health problems but not specifically hypertension. An unhealthy diet may contribute somewhat to the early development of hypertension, but it is more likely due to stress on the body as a result of CP.
The caregiver of a patient with cerebral palsy (CP) asks if there are any nonmedication interventions to help the patient. Which should the nurse explain as the goal for nonpharmacologic therapeutic interventions in the care of a patient with CP? Achieving the maximum level of independence Preventing injury from too much movement Allowing for better range of motion Promoting the ability to walk without assistance
Achieving the maximum level of independence Goals of nonpharmacologic interventions are for the patient to achieve the maximum level of independence possible. Assistive and positioning devices can be used to promote movement and prevent injury and may sometimes be used to allow independent ambulation, but these are not the primary goals.
During a routine exam, the nurse notices that a 2-year-old child shows signs of inadequate coordination and muscle stiffness. Which developmental disorder should the nurse suspect in this patient? Cerebral palsy Failure to thrive Autism spectrum disorder Attention-deficit/hyperactivity disorder
Cerebral palsy The patient may have the developmental disorder of cerebral palsy, which is characterized by inadequate balance and coordination (ataxia), uncontrolled movements (dyskinesia), and muscle stiffness (spasticity). The patient's symptoms are not associated with failure to thrive, autism spectrum disorder, and attention-deficit/hyperactivity disorder. Previous
The mother of a 4-month-old client is concerned that the client may be developmentally delayed. Which finding should lead the nurse to suspect cerebral palsy (CP) in the infant? A. Follows objects 180 degrees B. Tonic neck reflex C. Head lag D. Hypotonia
D. Hypotonia Rationale: Head lag, tonic neck reflex, and following objects 180 degrees are all normal for a 4-month-old infant. If head lag and tonic neck reflex persist beyond 6 months, then they would be a concern and suggest CP. Hypotonia is not normal and could be a sign of CP.
The nurse is caring for a client who has cerebral palsy (CP). Which intervention should the nurse use to promote flexibility and prevent contractures? A. Administer mood stabilizers B. Schedule speech therapy C. Provide muscle relaxants D. Perform range-of-motion (ROM) exercises
D. Perform range-of-motion (ROM) exercises Rationale: ROM exercises promote flexibility and prevent contracture formation. Muscle relaxants, mood stabilizers, and speech therapy do not promote flexibility or prevent contractures.
Which screening assessment should the nurse use for a child demonstrating developmental delays associated with cerebral palsy (CP)? (Select all that apply.) A. Heeldash shin test B. Babinski reflex C. Head turn D. Diaper pull E. Phalen test
C. Head turn D. Diaper pull Rationale: All infants who show symptoms of developmental delay should be evaluated by using two simple screening assessments. The first is a diaper pull, which is conducted by placing a clean diaper on the child's face; the infant with CP will use one hand or will not remove the cloth at all. The other test is the head turn, which is conducted by turning the infant's head to one side; if the child has a persistent asymmetric tonic neck reflex beyond 6 months of age, this indicates a pathologic condition. The Babinski reflex does not indicate the presence or absence of CP. The Phalen test is used to assess for carpal tunnel syndrome. The heeldash shin test is used with adults to determine nervous system integrity of the lower extremities.
The nurse is preparing discharge instructions for the parents of a child with cerebral palsy (CP). Which instruction should the nurse include to promote safety for this child? (Select all that apply.) A. Adaptive seating for automobile transportation B. Splints and braces C. Range-of-motion exercises D. Helmet to protect against head injuries E. Seat belts in strollers and wheelchairs
A. Adaptive seating for automobile transportation D. Helmet to protect against head injuries E. Seat belts in strollers and wheelchairs Rationale: A client who has frequent falls and/or seizures may require a helmet to protect against head injury. Adaptive seating in an automobile may be required to ensure proper, safe restraint. Use of seat belts in wheelchairs or strollers will prevent spastic movements from resulting in falls. Use of splints and braces and range-of-motion exercises will promote mobility and muscle strength; they are not used to promote safety.
A small-for-gestational age neonate is showing signs of poor development. Which factor should the nurse identify that increases this client's risk of cerebral palsy (CP) before or during birth? (Select all that apply.) A. Injury to the cerebral cortex B. Neonatal sepsis C. Fetal viral infection D. Premature birth E. Hyperbilirubinemia
A. Injury to the cerebral cortex C. Fetal viral infection D. Premature birth Rationale: Most cases of CP are caused before or during birth by a brain insult; this includes premature birth, fetal viral infection, and injury to the cerebral cortex. CP can also develop after birth to age 2 years, when it can be caused by neonatal sepsis and hyperbilirubinemia.
The mother of a 4-year-old child with cerebral palsy (CP) asks how this health problem occurred. Which prenatal insult should the nurse explain as a possible cause? (Select all that apply.) A. Prematurity B. Genetic factors C. Hyperbilirubinemia D. Fetal viral infection E. Brain injury
A. Prematurity B. Genetic factors D. Fetal viral infection Rationale: Prematurity is an etiology of CP that occurs before birth. Fetal viral infection is an etiology of CP that occurs before birth. Genetic factors are an etiology of CP that occurs before birth. Hyperbilirubinemia is an etiology of CP that occurs after birth. Brain injury is an etiology of CP that occurs after birth.
Which intervention should improve self-feeding ability in a child with spasticity caused by cerebral palsy (CP)? A. Providing utensils with adaptive handles B. Providing a low-fiber diet C. Presenting large portions of food all at one time D. Restricting hydration
A. Providing utensils with adaptive handles Rationale: Utensils with adaptive handles may improve self-feeding ability in children with spasticity associated with CP. Other possible interventions include feeding small amounts of food at a time. Restricting fluids and a low-fiber diet will not improve self-feeding ability in this client.
he nurse is preparing teaching material for the parents of a child with cerebral palsy (CP). Which treatment should the nurse include in this teaching? (Select all that apply.) A. A low-calorie diet B. Muscle relaxants C. Serial casting D. Positioning devices E. Surgery
B. Muscle relaxants C. Serial casting D. Positioning devices E. Surgery Rationale: Muscle relaxants may help the child with spasticity often associated with CP. Surgery may be helpful for children who experience contractures as a result of CP. Serial casting may be helpful for children with CP. Positioning devices are used to prevent contractures. A low-calorie diet is not recommended for children with CP.
The nurse notes a high level of stress between the parents of a child with cerebral palsy (CP). Which action should the nurse take to support the parents? A. Refer all medical questions to the healthcare provider B. Make a referral for marriage counseling C. Explain that all children with CP are eventually placed in long-term care facilities D. Listen to concerns and encourage expression of feelings
D. Listen to concerns and encourage expression of feelings Rationale: Parents require emotional support to help them cope with the diagnosis. Listen to the parents' concerns and encourage them to express their feelings and ask questions. The nurse should encourage the family to ask questions and should obtain answers to questions that the nurse is unable to answer. All children with CP are not eventually transferred to a long-term care facility; many are successfully cared for at home. Referrals for individual and family counseling are appropriate, but the nurse is not qualified to suggest a referral for marriage counseling.
