Ch 44 (neuromuscular/musculoskeletal disorder), 49 (genetic alterations), 2 (family centered care),

The nurse is doing client teaching with a child who has been placed in a brace to treat scoliosis. Which statement made by the child indicates an understanding of the treatment? Wearing this brace only during the night won't be so embarrassing." "At least when I take a shower I have a few minutes out of this brace." "When I start feeling tired, I can just take my brace off for a few minutes." "I am so glad I can take this brace off for the school dance."

"At least when I take a shower I have a few minutes out of this brace." Explanation: The brace worn to treat scoliosis is worn day and night and should be removed only very briefly, such as for showering. The child needs to be taught that the brace must be worn at all times, during the day as well as the night.

The parents of a infant born with an abnormality on the back are told by the neonatologist that their child has a myelomeningeocele. They ask the nurse what exactly that means. Which would be the nurse's best reply? "The contents of the sac you see only has fluid in it and should cause the child no problem." "It is a herniation through the skin of the back of your child with both the spinal cord and nerve roots involved." "The sac is a very small cyst and should resolve within the first year of life." "Your child's defect involves only the nerves to the bladder and bowel and can be easily repaired."

"It is a herniation through the skin of the back of your child with both the spinal cord and nerve roots involved." Explanation: A myelomeningocele is the more severe form of spina bifida cystica, in which the spinal cord and nerve roots herniate into the sac through an opening in the spine, compromising the meninges and usually resulting in neurological impairment. A meningocele includes the meninges and spinal fluid only. A myelomeningocele usually contains the bowel and bladder innervation but involves many more nerves also. A myelomeningocele is not just a cyst that resolves within a year.

Sensorimotor

-birth to 2 yrs -progresses from reflex activity through simple repetitive behaviors to imitative behaviors -develops sense of "cause and effect" -curiosity, experimentation, and exploration result in the learning process -object permanence3 is fully developed

A group of students are reviewing information about bone healing in children. The students demonstrate understanding of this information when they state: The process of breaking down and forming new bone is decreased in children compared with adults. A child's bones heal more quickly than those of an adult. Callus production is slower (but greater in amount) in children than in adults. A fracture closer to the growth plate heals much slower than one in the metaphysis.

A child's bones heal more quickly than those of an adult. Explanation: Bone healing occurs in the same fashion as in the adult, but it occurs more quickly in children because of the rich nutrient supply to the periosteum. The closer a fracture is to the growth plate, the more quickly the fracture heals. The capacity for remodeling (the process of breaking down and forming new bone) is increased in children compared with adults. Children's bones produce callus more rapidly and in larger quantities than do adults' bones.

A group of students are reviewing information about the skeletal development in children. The students demonstrate understanding of the information when they identify that ossification is complete by what age? Preschool age Adolescence Toddlerhood School age

Adolescence Explanation: Ossification and conversion of cartilage to bone continue throughout childhood and are complete at adolescence

A Hispanic woman in active labor begins to recite a Hispanic lullaby to "call the baby outside." Which action by the nurse caring for this woman is most appropriate at this time? Ask the woman the importance of this lullaby to her culture. Allow the client to perform a ritual. Administer IV pain medication. Ask the family to join in with the singing of this lullaby.

Allow the client to perform a ritual. Explanation: The nurse can acknowledge and celebrate a client's culture without stereotyping by such actions as ensuring that the client has the opportunity to perform her cultural traditions during labor, such as reciting a Hispanic lullaby to "call her child outside." There is no indication that pain medication is needed at this time. When one respects the culture, quizzing about the purpose or importance of reciting this lullaby is inappropriate.

The nurse notes that a 5-year-old boy is approaching obesity. Which is the priority intervention? Asking about culturally related eating habits Assessing the diet of the child and family Screening the child for metabolic disorders Determining the activity level of the child

Assessing the diet of the child and family Explanation: The greatest influence on the child's behaviors is the family. Therefore, habits of the family are likely to be those of the child. Evaluating the family diet is most important. Determining the activity level of the child ranks next in importance. Sedentary behaviors lead to weight gain. Asking about culturally related eating habits can produce some helpful but limited nutrition information. Screening the child for metabolic disorders would not be done unless there was other evidence that points to this possibility.

A child is born with a talipes disorder. The child later receives a cast on the affected leg to correct the problem. Which measure should the nurse mention to the mother to ensure good circulation in the affected leg? Apply Denis Browne splints to the infant each night. Perform passive foot exercises. Change the infant's diapers frequently. Check the infant's toes for coldness or blueness.

Check the infant's toes for coldness or blueness. Explanation: Review with parents how to check the infant's toes for coldness or blueness and how to blanch a toenail bed and watch it turn pink to assess for good circulation. The other answers are other interventions pertaining to caring for a child with a talipes disorder but are not associated specifically with ensuring good circulation.

Upon assessment, the nurse notices that the infant's ears are low-set. What is the priority action by the nurse? Inform the parents that low-set ears are a sign of Down syndrome Place the infant on a cardiac monitor Give a vitamin B12 injection to combat the metabolic disorder Continue to assess the infant to look for other abnormalities

Continue to assess the infant to look for other abnormalities Explanation: Continue to assess for major and minor congenital anomalies because major anomalies may require immediate medical attention. Three or more minor anomalies increase the chance of a major anomaly. Low-set ears can be a symptom of a variety of genetic disorders. Mentioning Down syndrome without further investigation can cause undue stress in parents. The infant may not need cardiac monitoring; further assessment will provide clues. Diagnostic testing is needed to determine whether the child is afflicted with a metabolic disorder.

Which laboratory or diagnostic test would the nurse anticipate to rule out complications related to Down syndrome? Chromosomal analysis Echocardiogram Ultrasound-guided amniocentesis Chorionic villi sampling

Echocardiogram Explanation: Many Down syndrome children have cardiac complications. Chorionic villi sampling, chromosomal analysis, and amniocentesis are diagnostic tools used to diagnose genetic disorders, not complications associated with a genetic disorder.

The nurse caring for a client in a body cast knows that immobility can cause contractures, loss of muscle tone, or fixation of joints. Which nursing interdisciplinary intervention is recommended to help prevent these adverse conditions? Give the client large, frequent meals with decreased fiber and increased protein and Vitamin C. Encourage active and passive range-of-motion activities to prevent ineffective tissue perfusion. Encourage child to stifle cough and take shallow breaths to prevent ineffective breathing patterns. Check for a normal capillary refill of 3 to 5 seconds on a daily basis to ensure there in adequate arterial supply.

Encourage active and passive range-of-motion activities to prevent ineffective tissue perfusion. Explanation: The nurse should turn the client and encourage active and passive range-of-motion activities to prevent ineffective tissue perfusion. The client should be instructed to cough and breathe deeply to prevent respiratory complications. Normal capillary refill is 1 to 3 seconds. The client should be given small, frequent meals with increased fiber, protein, and vitamin C to prevent malnutrition.

To assess the sociocultural aspects of the family of an adolescent in an ambulatory clinic, what would you try to find out more about? The adolescent's education level His family structure His mother's occupation His mother's attitude toward citizenship

His family structure Explanation: Family structure is a characteristic strongly influenced by culture and ethnicity.

An 18-year-old male is diagnosed with Klinefelter syndrome. What signs and symptoms are consistent with this diagnosis? Hypogonadism and gynecomastia Hypergonadism and decreased pubic hair Long torso and decreased facial hair Enlaged testes and tall stature

Hypogonadism and gynecomastia Explanation: Klinefelter syndrome affects males, causing only testosterone deficiency. Males may develop female-like characteristics such as gynecomastia and may experience hypogonadism. Decreased pubic and facial hair, along with tall stature, are characteristic of the disorder. The corresponding signs and symptoms listed in the other answer selections are not signs and symptoms of the disorder.

A newborn was screened for hereditary metabolic disorder at 8 hours old. Which action by the nurse is most appropriate? Instruct the parent to have another screening in 1 to 2 weeks Repeat screening in 8 hours No further intervention is needed If the infant is premature, screening needs to be done every 8 hours for 48 hours

Instruct the parent to have another screening in 1 to 2 weeks Explanation: Screening for hereditary metabolic disorders should be done after the first 24 hours of life because of the higher incidence of false-positive results. Repeating the screening in 8 hours or every 8 hours for 48 hours would yield the same increased risk for false-positives.

The nurse is assessing the eyes of a 6-month-old and notices that she has wide-spaced eyes and bilateral epicanthal folds. Which condition associated with these findings should also be assessed for in this child? Amblyopia Low-set, malformed ears Strabismus Ptosis

Low-set, malformed ears Explanation: Hypertelorism is congenital, abnormally wide-spaced eyes. Detecting true hypertelorism in children is important, because this condition is associated with chromosomal abnormalities such as Cri-du-chat syndrome. Cri-du-chat syndrome is an abnormality on chromosome 5 and is associated with intellectual and developmental disability. Children with this syndrome also have short stature, microcephaly, a simian crease and a weak, cat-like cry during infancy. None of the other conditions is associated with hypertelorism.

Reaction to illness & hospitalization: adolescents

Major fears -loss of independence -loss of identity -body image disturbance -rejection by others

Reaction to illness & hospitalization: school-age

Major fears -pain & bodily injury -loss of control -fears often related to school, peers, and family

Reaction to illness & hospitalization: infant/toddlers

Major fears -separation anxiety -regression

Which concept characterizes transcultural nursing? Acknowledging that clients with the same skin have similar social situations Performing health-related activities and restoring wellness Planning care compatible with the client's health belief system Influencing culture by specific conditions related to an environment

Planning care compatible with the client's health belief system Explanation: Planning care compatible with the client's health belief system is a characteristic of transcultural nursing. Acknowledging that clients with the same skin color have similar social situations leads to stereotyping. Stereotyping can be dangerous because it is dehumanizing and also interferes in accepting others as unique individuals. Culture is influenced by specific conditions related to environment. Performing health-related activities and restoring wellness is an important aspect of nursing and does not only pertain to transcultural nursing.

The nurse is conducting a physical examination of a 9-month-old infant with a suspected neuromuscular disorder. Which finding would warrant further evaluation? Absence of Moro reflex Absence of tonic neck reflex Presence of symmetrical spontaneous movement Presence of Moro reflex

Presence of Moro reflex Explanation: The persistence of a primitive reflex in a 9-month-old would warrant further evaluation. Symmetrical spontaneous movement and absence of the Moro and tonic neck reflex are expected in a normally developing 9-month-old child.

What will be the nurse's next action after noting dimpling and a tuft of hair located in the lumbosacral area of the preschool child during examination? Move on to other assessments without calling attention to the difference Snip the tuft of hair off close to the skin for hygienic reasons Record and refer the finding for follow-up to the pediatrician Inspect for precocious hair growth in the genital and underarm areas

Record and refer the finding for follow-up to the pediatrician Explanation: Dimpling and hair growth may signal spina bifida occulta, which usually is benign. However, some complications can be associated, and further investigation is warranted to prevent possible damage to the spinal cord. Magnetic resonance imaging (MRI) is often the diagnostic tool used. No hygienic concerns need prevail. These findings do not suggest development of precocious puberty or any other hormonal problem. The dimpling and hair tuft must be clearly explained to the parents.

Which nursing diagnosis is most relevant in the first 12 hours of life for a neonate born with a myelomeningocele? Risk for infection Delayed growth and development Impaired physical mobility Constipation

Risk for infection Explanation: All of these diagnoses are important for a child with a myelomeningocele. However, during the first 12 hours of life, the most life-threatening event would be an infection. The other diagnoses will be addressed as the child develops.

The student nurse is studying the genetics of clients who are seeking assistance from a genetic counseling center. The student nurse notes monogenic disorders have which characteristic? The disorders are considered single-gene The disorders are considered multifactorial Inheritance The disorders are considered mitochondrial inheritance patterns The disorders are considered nontraditional inheritance patterns

The disorders are considered single-gene Explanation: Principles of inheritance of single-gene disorders are the same that govern the inheritance of other traits, such as eye and hair color. These patterns occur because a single gene is defective and the disorders that result are referred to as monogenic or, sometimes, mendelian disorders.

What is the main purpose of nurses having basic genetic knowledge? To understand all genetic disorders, allowing for improved quality of life To ensure proper medical diagnosis To provide support and education to families To advocate for a cure for genetic disorders

To provide support and education to families Explanation: The purpose of the nurse knowing about basic genetics is that it helps her to provide support and education to families. Nurses can advocate for a cure, but this is not the main purpose of attaining basic knowledge of genetics. Providing a medical diagnosis is beyond the scope of practice for a nurse. It would be impossible for the nurse to understand all genetic disorders; it is more reasonable for the nurse to be familiar with the most common genetic disorders.

Pertussis -Transmission -Tx

Transmission- droplet/contact (highly contagious for young infants) Tx- supportive

Rubeola -Transmission -Tx

Transmission- droplet/contact (sometimes requires airborne isolation_ Tx- supportive

Idiopathic scoliosis is the most common form that occurs. True False

True Explanation: Idiopathic scoliosis, with the majority of cases occurring during adolescence, is the most common scoliosis.

A neonatal nurse examines an infant and notes decreased hip motion that causes pain upon movement. This nurse suspects Legg-Calvé-Perthes disease, a common pediatric hip disorder that causes pain and decreased hip motion, possibly leading to a femoral head deformity. True False

True Explanation: Legg-Calvé-Perthes disease is a common pediatric hip disorder that causes pain and decreased hip motion, possibly leading to a femoral head deformity. It has an incidence of 1 per 1,200 live births, with some hereditary factors influencing incidence.

The nurse caring for a child who has been put into a leg cast must be on the alert for signs of nerve and muscle damage. Which symptom might be an early warning signal that the child has developed compartment syndrome? The child: cannot plantarflex his foot. feels increasing severe pain. has a weak femoral pulse. has blue-looking nail beds on the toes.

feels increasing severe pain. Explanation: Any reports of pain in a child with a new cast or immobilized extremity need to be explored and monitored closely for the possibility of compartment syndrome.

A nurse is describing the underlying cause of trisomy 21 to a group of parents, integrating knowledge that the disorder is due to: duplication. nondisjunction. deletion. translocation.

nondisjunction. Explanation: Trisomy 21 is a disorder caused by nondisjunction or error in cell division. It is not due to the loss of a portion of the chromosome (deletion), an extra segment being present (duplication), or transfer of one part of the chromosome to another (translocation).

A 19-year-old pregnant adolescent who experienced a rape has arrive in the emergency department in active labor with no prenatal care. The nurse caring for the client should assess for which potential adverse health problem? sexually transmitted infections (STIs) gestational diabetes hypertension caused by preeclampsia alcohol withdraw symptoms

sexually transmitted infections (STIs) Explanation: Any pregnant female who arrives in the emergency department without any prenatal care may be at increased risk for adverse health conditions, which may include STIs. It is rare for a younger client to develop gestational diabetes or preeclampsia. There is no indication that the client was intoxicated and at risk for alcohol withdraw.

average growth (weight)

toddler- 4x birth weight by 2 1/2 yrs preschooler- 4-5 lbs/yr school-age- 5lbs/yr adolescence- girls 15-55lbs, boys 15/65lbs

Athetoid or Dyskinetic CP

-2nd most commonly diagnosed CP -poss. problems controlling facial muscles, could cause drooling issues -normal intelligence but body will be totally affected w/ problems

Types of CP

-Spastic (most common) -Athetoid or Dyskinetic -Ataxic -Mixed

Food introductions for infants

4-6 months- rice cereal 6-8 months- fruits/veggies 8-10 months- meats no honey until at least 1 yr no eggs, strawberries, wheat, corn, fish, or nuts until close to 2-3 yrs

Types of spastic CP

Hemiplegia- one side of body affected Diplegia- lower ext. affected Quadriplegia- legs, arms, and body affected. More likely to have mental retardation

Which information is true of home care as a whole? It is decreasing because the overall incidence of children's illnesses is decreasing in number. It is decreasing because many new care measures are too technical for use in the home. It is increasing because new technology makes so many procedures available in the home. The amount of care remains even because only a limited number of nurses are available to give care.

It is increasing because new technology makes so many procedures available in the home. Explanation: Home care is expanding because it can offer advantages to both caregivers and consumers. New technology makes it successful.

pharmacological management for CP

Oral meds- baclofen, diazepam, and dilantin (and other anticonvulsant meds, to prevent and control sz activity) Athetoid CP- pt may be given anticholinergics to help decrease abnormal movements, Robinal (glycopyrrolate) help decrease saliva and help to control drooling

industry vs inferiority

-6-12yrs -displays development of new interests and involvement in activities -learns to follow rules -acquires reading, writing, math, and social skills -if successful, develops confidence and enjoys learning about new things; if compared to others, may develop feelings of inadequacy: inferiority may develop if too much is expected

The child has been diagnosed with rickets. The child's mother is educated about the importance of providing the child with 10 micrograms (400 International Units) of an oral vitamin D supplement each day. The child's mother purchases over-the-counter vitamin D drops. The supplement is noted to contain 5 mcg of vitamin D in each 0.5 mL. How much of the supplement should the mother administer to the child each day? Record your answer using one decimal place.

1 Explanation: The supplement has 5 mcg of vitamin D in each 0.5 mL. The child is supposed to receive 10 mcg each day of supplemental vitamin D. Desired/Have x Quantity = dose 10 mcg/5 mcg x 0.5 mL = 1.0 mL Ratio/proportion: 0.5 mL/5 micrograms = x/10 micrograms = 1.0 mL

A child with a diagnosis of Down syndrome has had which of the following chromosome abnormalities occur? 3 copies of trisomy 13 has occurred instead of 2 copies. 3 copies of trisomy 21 has occurred instead of 2 copies. 3 copies of trisomy 18 has occurred instead of 2 copies. 1 copy of the chromosome 8 has occurred instead of 2 copies.

3 copies of trisomy 21 has occurred instead of 2 copies. Explanation: A child with Down syndrome has trisomy 21, which means 3 copies of chromosome 21 has occurred instead of 2 copies. If this occurs with chromosome 18, it leads to Edward's syndrome, and if it occurs with chromosome 13, it leads to Patau syndrome.

Reaction to illness & hospitalization: preschoolers

Major fears -mutilation RN interventions -therapeutic play

Which statement by the parent of a 12-month-old child diagnosed with Down syndrome shows the need for further education? "In a couple of years, my child will need an x-ray of the neck." "I will need to delay any further immunizations." "I will watch closely for development of respiratory infection." "Thyroid testing is needed every year."

"I will need to delay any further immunizations." Explanation: Down syndrome children are at higher risk for infection because of a lowered immune system. Delaying immunizations may expose the child to illnesses that could have been prevented. Down syndrome children are at greater risk for developing thyroid disorders, 1st and 2nd vertebrae disorders, and respiratory infections.

The nurse is caring for an 8-year-old girl in traction. She has been in an acute care setting for two weeks and will require an additional 10 days in the hospital. She is showing signs of regression with thumb sucking and pleas for her tattered baby blanket. What would be the most helpful intervention? "Would you like a coloring book?" "Do you want a book to read?" "Let's ask your mom to bring your friends for a visit." "You are too big to suck your thumb."

"Let's ask your mom to bring your friends for a visit." Explanation: After two weeks in traction, a child can become easily bored and regress in social and personal skills. A visit from friends arranged by the girl's mother or supervised by the child-life specialist would help her adapt to her immobilized state. Telling the girl she is too big to suck her thumb is unhelpful. Suggesting a book or coloring book would be unhelpful at this point, as she has likely grown tired of books and coloring after two weeks.

The nurse is caring for a child of Asian descent. The nurse is trying to ensure that the family's cultural practices are supported. Which statement by the nurse indicates a lack of understanding regarding cultural competence? "Are there any dietary practices related to your culture that we should know about?" "Most cultures have certain practices that are important to them. We want to honor any that we can." "Is there a particular religion that we should note in your chart that may impact your care?" "Since your child is only 8, I doubt that your child has any cultural practices we need to be aware of."

"Since your child is only 8, I doubt that your child has any cultural practices we need to be aware of." Explanation: Typically, a child begins to understand his or her culture at approximately 5 years of age, so stating that the child does not have any cultural practices at the age of 8 is inaccurate. Diet, cultural practices, and religious practices related to culture are important for the nurse to know so that the nursing staff can support as many of these practices as possible.

formal operation

-11-death -able to logically manipulate abstract and unobservable concepts -adaptable and flexible -able to deal with contradictions -uses scientific approach to problem solving -able to conceive the distant future

Rubeola 1-stages 2-s/s & tests 3-NANDA's

1-Stage -Catarrhal- 3 C's -Paroxysmal- Kopliks spots, rash -Convalescent- skin peeling 2-s/s & tests -cough, coryza, conjunctivitis, fever, Koplil spot, rash -CBC (CRP), temp., electrolyte (dehydration chem panel) 3-NANDA's -R/F 2* infection R/T skin lesions -Impaired skin integrity R/T skin peeling & itching -Impaired gas exchange R/T coryza, cough -R/F altered cerebral tissue perfusion

Personal space and distance is a cultural perspective that can impact nurse-client interactions. What is the best way for the nurse to interact with a client who has a different cultural perspective on space and distance? Realize that sitting close to the client is an indication of warmth and caring. Adopt a cultural preference similar to that of the client. Allow the client to adopt a position that is comfortable for him or her. Remember not to intrude into the personal space of the elderly.

Allow the client to adopt a position that is comfortable for him or her. Explanation: If the client appears to position himself or herself too close or too far away, the nurse should consider cultural preferences for space and distance. Ideally, the client should be permitted to assume a position that is comfortable to him or her in terms of personal space and distance. "Realizing" and "remembering" are not interactions. It is also incorrect to attempt to adopt someone else's cultural preference as this can be very uncomfortable for the nurse, which adds a barrier to nurse-client interactions.

Which statement about nondisjunction of a chromosome is true? It may result from genomic imprinting. It is failure of the chromosomal pair to separate. Only 4% of Down syndrome cases are attributed to this defect. Only the X chromosomes are affected.

It is failure of the chromosomal pair to separate. Explanation: Nondisjunction simply means failure to separate. Nondisjunction can happen at any chromosome and is attributed to 95% of Down syndrome cases. Genomic imprinting is a different genetic disorder that is not related to nondisjunctioning.

The nurse caring for a client with suspected muscular dystrophy would prepare her client for which diagnostic test? EEG Muscle biopsy Assessment of ambulation X-ray

Muscle biopsy Explanation: Muscle biopsy provides definitive diagnosis of muscular dystrophy demonstrating the absence of dystrophin. X-ray is best for identifying an osseous deformity. Ambulation assessment alone wouldn't confirm diagnosis of this client's disorder. EEG wouldn't be appropriate in this case.

What are examples of culturally sensitive care? Select all that apply. Providing discharge instructions in Spanish to a Hispanic patient who speaks in broken English. Advocating for a postpartum client to stay in the hospital an extra day to rest. Nodding hello instead of shaking hands with an Orthodox Jewish male. Providing a Middle Eastern woman an extra gown for covering up.

Providing discharge instructions in Spanish to a Hispanic patient who speaks in broken English. Nodding hello instead of shaking hands with an Orthodox Jewish male. Providing a Middle Eastern woman an extra gown for covering up. Explanation: Advocating for a client who needs rest and providing family-centered care are great nursing skills. However, these skills are not culturally specific and are relevant to all clients. Awareness of clients' cultural differences such as the preference of an Orthodox Jewish man who does not want to shake hands or of a Muslim American woman who desires extra modesty, and providing instructions in the language that is most comfortable for the client are examples of culturally sensitive care.

A client with hypertension tells her nurse that she would like to use an herbal substance (CAM) to lower her blood pressure instead of taking the antihypertensive medication. The nurse should: tell the client that if she uses the herbal substance, she will need to check her blood pressure daily. show the client how to take her blood pressure so she can monitor it closely. advise the client to speak with her primary care provider about combining herbal substances with her medication. tell the client that she should never use herbal substances because they are dangerous.

advise the client to speak with her primary care provider about combining herbal substances with her medication. Explanation: The nurse should ensure that the client speaks with her primary care provider. Clients who are being treated with conventional medication therapy should be advised to avoid herbal substances because they may lead to unknown interaction effects.

most common preventative therapy for TB

daily dose of INH for 6-12 months

A parent asks why a physical therapist is needed for the 6-month-old child diagnosed with Down syndrome. What is the best response by the nurse? "To ensure that the child meets all developmental milestones on time" "To prevent contractures" "The earlier the intervention, the more likely we are to cure the problem" "To optimize the child's development and functioning"

"To optimize the child's development and functioning" Explanation: Interventional therapy is started early to promote the child's development and optimize functioning. The Down syndrome child usually meets developmental milestones at a slower pace. There is no cure for genetic disorders. Range-of-motion activities can prevent contractures; Down syndrome does not require physical therapy.

concrete operation

-7-11 yrs -thoughts become increasingly logical and coherent -able to shift attention from one perceptual attribute to another (decentration) -concrete thinkers; views things as black and white, right or wrong, no in between or gray areas -able to classify and sort facts, do problem solving -acquires conservation skills

Ataxic CP

-Least diagnosed -trouble w/ fine motor skills -May walk w/ feet further apart, trouble w/ balance and coordination -suffer from tension tremors, shaking w/ involuntary movement, tremors worsen when they get closer to the object that they are reaching for

3 stages of separation anxiety

-protest -despair -detachment

identity vs role confusion

-rapid and marked physical changes -preoccupation w/ physical appearance -examines and redefines self, family, peer, group, and community -experiments with different roles -peer group very important -if successful, develops confidence in self-identity and optimism; if unable to establish meaningful definition of self, develops role confusion

PPD test

-read in 48-72 hrs after injection -areas of induration - <5mm- negative response (doesn't r/o infection) - 5-9mm- + for people who: close contact w/ TB, abnormal CXR, HIV or immunocompromised, organ transplant, - for all others - 10-15mm- + for people w/ other risk factors - >15mm- + for all people *false positive- pt's w/. BCG vaccines

The nurse is assessing infants in the newborn nursery. Who is most likely to have a major anomaly? 12-hour-old Caucasian male with café-au-lait spots on his trunk Set of 6-hour-old Indian American identical twin females with syndactyly 16-hour-old African American male with polydactyly 4-hour-old Asian American female with protruding ears

12-hour-old Caucasian male with café-au-lait spots on his trunk Explanation: A major anomaly is an anomaly or malformation that creates significant medical problems and requires surgical or medical management. Café-au-lait spots are a major anomaly. Polydactyly, or extra digits, syndactyly, or webbed digits, and protruding ears are minor anomalies. Minor anomalies are features that vary from those that are most commonly seen in the general population but do not cause an increase in morbidity in and of themselves.

The nurse recognizes that which individual or couple would most benefit from obtaining genetic counseling? 23-year-old female, 25-year-old-male, both with family history of sickle cell disorder 32-year-old female, 25-year-old male with one pregnancy loss 30-year-old female with a normal alpha-fetoprotein screening 25-year-old female, 40-year-old male, both with no significant past medical history

23-year-old female, 25-year-old-male, both with family history of sickle cell disorder Explanation: A family history of sickle cell disorder increases the risk of passing the disorder to offspring; genetic counseling would benefit this couple most. The usual standard for counseling for pregnancy loss is two or more, not a single loss. A normal alpha-fetoprotein screening is not a criterion for genetic counseling. All ages listed here do not exceed the criterion for advanced maternal or paternal age.

The nurse is caring for a group of children on the pediatric unit. The nurse should collect further data and explore the possibility of child abuse in which situation? A 7-year-old with a spiral fracture of the humerus, which the caregiver reports as having been caused when the child was hit by a bat swung by a Little League teammate. A 6-year-old with a greenstick fracture of the wrist, which the caregiver reports as having been caused when the child fell while ice-skating. A 10-year-old with a simple fracture of the femur, which the caregiver reports as having been caused when the child fell down a set of stairs. A 9-year-old with a compound fracture of the tibia, which the caregiver reports as having been caused when the child attempted a flip on a skateboard.

A 7-year-old with a spiral fracture of the humerus, which the caregiver reports as having been caused when the child was hit by a bat swung by a Little League teammate. Explanation: Spiral fractures, which twist around the bone, are frequently associated with child abuse and are caused by a wrenching force. When a broken bone penetrates the skin, the fracture is called compound, or open. A simple, or closed, fracture is a single break in the bone without penetration of the skin. In a greenstick fracture, the bone bends and often just partially breaks.

A child admitted for gastritis and vomiting has a medical history of medium-chain acyl-coA dehydrogenase deficiency (MCAD). What is the priority action by the nurse? Ensure that frequent small meals are available Give IV thiamine supplement as ordered Ensure that the diet includes no dairy products Administer IV dextrose per orders

Administer IV dextrose per orders Explanation: MCAD children lack the enzyme needed to metabolize fatty acids. They have frequent episodes of hypoglycemia as a result of the disorder. Because the child is vomiting, frequent small meals would not be tolerated. The child needs IV dextrose to combat hypoglycemia. Dairy products do not affect the child's metabolic disorder; although they could cause further issues with gastritis, this would not be the priority intervention. This disorder is not associated with thiamine deficiency.

A nurse is applying a cast to a 12-year-old boy with a simple fracture of the radius in the arm. What is most important for the nurse to do when she has finished applying the cast? X-ray the cast to make sure the bones are aligned properly Assess the fingers for warmth, pain, and function Apply a tube of stockinette over the cast Cut a window in the cast over the wrist

Assess the fingers for warmth, pain, and function Explanation: Assess fingers or toes carefully for warmth, pain, and function after application of a cast to be certain a compartment syndrome is not developing. Before a cast is applied, not after, a tube of stockinette is stretched over the area, and soft cotton padding is placed over bony prominences. A "window" may be placed in a cast for an open fracture or if an infection is suspected—not to prevent an infection—so that the area can be observed; however, a window is not indicated in this case. The x-ray should be performed before casting, to diagnose the fracture, not afterward.

A couple who has been married for 10 years chose to postpone having children until their professional careers were established. They now feel ready to start a family. After many months of trying, they are consulting with a fertility expert. The nurse should anticipate that this couple may be experiencing which NANDA due to the negative aspect of postponing pregnancy? Parental role conflict Ineffective childbearing process Ineffective relationship Risk for impaired attachment

Ineffective childbearing process Explanation: Ineffective childbearing process is the only NANDA that relates to the process by which human beings are produced. The other NANDAs listed relate to role relationships. Risk for impaired attachment is associated with family relationships (i.e., people who are biologically related). Parental role conflict and Risk for impaired attachment are associated with role performance or the quality of functioning in socially expected behavior patterns.

The parents of a 3-month-old bring their baby to the clinic with vomiting, irritability, and an eczema-like rash. The nurse notices that the infant's urine smells musty. The parents state the baby was born at home and this is the first time the infant has been seen by a health care practitioner. The nurse is aware that this infant is most likely exhibiting sign of which disorder? Biotinidase deficiency Achondroplasia Phenylketonuria Galactosemia

Phenylketonuria Explanation: Phenylketonuria (PKU) is a deficiency in a liver enzyme leading to inability to process the essential amino acid phenylalanine properly. Phenylalanine is found mostly in protein-containing foods such as meat and milk (including breast milk and formula). The disease has no symptoms at birth. Most cases are identified before symptoms are present due to newborn screening (PKU is screened for in all states). Since this child was born at home the disease was not diagnosed.

A laboring woman has brought her partner as her support person who is dressed in feminine attire, but when she speaks, it is clear to the nurse that the support person has a male voice. When documenting about the client's support person, which term would be most appropriate? male who likes to dress like a woman drag queen transgender gender dysphoria

transgender Explanation: A transgender person is an individual whose gender identity does not match the sex assigned at birth. Gender dysphoria is the realization one's physical sex and gender are mismatched, which can cause a lot of stress and anxiety. There is no data that supports the partner is experiencing anxiety. Drag queen is a slang, inappropriate term. The term "male who likes to dress like a woman" is making a judgment statement and not appropriate in a medical document.

A pregnant woman experiencing morning sickness has asked her nurse about ways to reduce or alleviate it. After receiving education and information from the nurse, which statement would indicate that the client understood the information? "My mother told me that she took vitamins to reduce the sickness and there wasn't a problem." "I really don't think there's anything wrong with taking a few vitamins." "I'll discuss with my primary care provider whether it is a good idea for me to use sea-bands." "I'll just drink less ginger tea than I used to."

"I'll discuss with my primary care provider whether it is a good idea for me to use sea-bands." Explanation: All therapies (complementary and alternative) should be discussed with the primary care provider. Although some CAM therapies can help alleviate pain or sickness, all pregnant women should understand that these substances cross the placenta and can reach the growing embryo. In addition, many CAM therapies have not undergone scientific study and can place the woman at risk when mixed with traditional medicine.

An adolescent client who has scoliosis and is wearing a Milwaukee brace tells the nurse that she is ugly and cannot wear the same clothing as her friends. Which response by the nurse best addresses this client's altered self-image? "Just hold your head up and be confident in how you look. Look for some after-school activities you can do wearing your brace." "You should not worry about what everyone else is wearing. You look fine." "Let's look at some clothing that you can wear with the brace that will look like everyone else's clothes but cover it." "Kids can be cruel sometimes. Has anyone told you that you look different?"

"Let's look at some clothing that you can wear with the brace that will look like everyone else's clothes but cover it." Explanation: A positive self-image is very important for adolescents wearing a brace. They want to look like their peers and wear the same clothing, but often that is not possible when wearing a brace. Assisting the adolescent in selecting clothing that looks stylish but still hides the brace is one of the best ways to help this client. Telling her she looks fine, to be confident, or bringing up the times she has been embarrassed does not help the client.

TB 1-stages 2-s/s & tests 3-NANDA's

1-Stages -Active- s/s present, contagious, abnormal CXR -Latent- no s/s, +PPD but -CXR, not contagious 2-s/s & tests -weight loss, cough, night sweats, fever, fatigue, coughing > 3 weeks -PPD, QFT, CXR, sputum culture 3-NANDA's -Impaired gas exchange -Ineffective airway clearance -Social isolation -Imbalance nutrition < body requirements -Fatigue -Non-compliance

Pertusis aka whooping cough 1-stages 2-s/s & tests 3-NANDA's

1-Stages -Catarrhal- URI symptoms, fever, mild cough -Paroxysmal- whooping cough, cyanosis -Convalescent- recovery phase, decreased cough, lasts weeks/months 2-s/s & tests -hypoxia, SOB, whistling/wheezing, cough, apnea, poss PNA -CXR, sputum culture, CBC, PCR, BMP 3- NANDA's -Ineffective breathing pattern -Impaired gas exchange -Risk for aspiration -Risk for fluid volume deficit -Ineffective airway clearance -Risk for malnutrition

Early signs of CP

-stiff or floppy posture -excessive lethargy or irritability/high pitched cry -poor head control -weak suck/tongue thrust/tonic bite/feeding difficulites

A mother is angry about her son's diagnosis of osteosarcoma. She is telling him that if he had not played football last year and broken his leg, this would not have happened. What is the nurse's best response to the mother's statement? "Playing sports does not cause osteosarcoma. It may draw attention to the weakened bone from the tumor, though." "Does bone cancer run in your family? Maybe he inherited it through his genes." "When he broke his leg last year, it may have weakened the bone, allowing cancer to start there." "Cancer in the bone can result from old injuries so it probably was not caused from getting hurt last year, but an earlier injury."

"Playing sports does not cause osteosarcoma. It may draw attention to the weakened bone from the tumor, though." Explanation: Osteosarcoma does not result from bone injuries but may be diagnosed when there is a fracture secondary to bone weakening from the tumor. Playing sports has no effect on development of osteosarcoma

A couple who are pregnant with their first child have made an appointment with a clinical geneticist to discuss prenatal screening. The man states that they, "just want to make sure that there is nothing wrong with our baby." How could the clinician best respond to this statement? "You need to be aware that if abnormalities are detected, termination is normally required." "Prenatal screening is not usually necessary unless you are among a high-risk group." "Testing the umbilical blood and performing amniocentesis can give us some information, but not a guarantee." "We can't rule out all abnormalities, but a routine fetal tissue biopsy can yield useful information."

"Testing the umbilical blood and performing amniocentesis can give us some information, but not a guarantee." Explanation: Prenatal screening provides a useful, but incomplete, picture of fetal health; umbilical sampling and amniocentesis are common methods of screening. Fetal tissue biopsy is a rarely-used screening method, and a couple need not belong to a high-risk group to benefit from prenatal screening. Abnormalities do not usually necessitate termination.

The caregiver of a child who has had a cast applied to the leg observes the nurse putting adhesive tape strips around the edge of the cast. The caregiver asks the nurse why she is doing this. The best response by the nurse would be: "We put these on so the child will not pull the padding from under the cast." "These will help the cast look more attractive so the child won't feel self-conscious." "In case the child has an accident and misses the bedpan, these can be changed to keep the area dry." "These make a smooth edge on the cast so the skin is better protected."

"These make a smooth edge on the cast so the skin is better protected." Explanation: If the cast has no protective edge, it should be petaled with adhesive tape strips. These help keep the skin protected from the rough edge of the cast. If the cast is near the genital area, plastic should be taped around the edge to prevent wetting and soiling of the cast; petaling the cast does not provide protection to keep the cast dry.

Varicella aka chicken pox 1-stages 2-s/s & tests 3-NANDA's

1-Stage -10-21 day incubation period -most contagious 1-2 days before rash & 5-6 days until lesions crust over 2-s/s & tests -Dx w/ fever, rash, itching -Develop in crops, vesicular rashes, super itchy, BODY WIDE 3-NANDA's -R/F 2* bacterial skin infection -Pain -Impaired skin integrity -Disturbed body image -Hyperthermia -R/F fluid volume deficit

The nurse is talking with a pregnant woman who is a carrier for a genetic disorder. The woman does not have any symptoms of the disorder. The pregnant woman asks the nurse about the risk to her unborn baby. What is the most appropriate response by the nurse? "There is no way to assess the risk to the baby until after he is born." "Since you are only a carrier for the gene, there is no risk to your baby." "We can only assess the potential risk after the baby's father undergoes genetic testing." "As a carrier of the gen,e there is a strong chance your child will be born with the disorder."

"We can only assess the potential risk after the baby's father undergoes genetic testing." Explanation: When an individual is a carrier for a genetic disorder the risk can only be assessed after viewing the genetic profile of the other parent. If the child's father is not a carrier of the gene or have the disorder there is no risk for the child to have the disorder. The child, however, can be a carrier like the mother.

An infant was born with a severely deformed hand. He is now 6 months old. The nurse informs the parents that the orthopedic surgeon has recommended amputation of the hand and fitting of a prosthesis. The mother objects and tells the nurse that they would like to wait and see how the hand develops. Which of the following should the nurse say in response? "I agree. You should wait until your son is older and let him decide whether he would like to have it done." "An alternative to amputation and prosthesis is administration of a new drug that can help regenerate the hand." "If we perform the amputation and you change your mind later, the hand can always be surgically reattached." "With a deformity such as this, the hand is highly unlikely to improve."

"With a deformity such as this, the hand is highly unlikely to improve." Explanation: Depending on the condition, in many children, there is a potential for better function if the malformed portion of an extremity is amputated before a prosthesis is fitted. This creates a difficult decision for parents because it is one they cannot undo later. They need assurance hands with malformed fingers, for example, will not later grow to become normal and a well-fitted prosthesis will allow their child a more usual childhood and adult life than if the original disorder was left unchanged. It is not the nurse's place to insert her opinion about the matter.

A 16-year-old recently diagnosed with Marfan syndrome states, "I feel fine. Why do I need to have this testing done?" What is the best response by the nurse? "The lab work will let us know if you are developing diabetes as a complication." "You are at risk of rupturing your aorta, and the echocardiogram will let us know if there are any problems." "You want to live a long time, right?" "This is routine. Nothing to worry about."

"You are at risk of rupturing your aorta, and the echocardiogram will let us know if there are any problems." Explanation: Marfan sydrome is a disorder that affects connective tissue. The aorta is susceptible to weakening because of the connective tissue disorder, leading to sudden death from aortic dissection. Diabetes is not a complication of Marfan syndrome. The other two choices offer no information and dismiss the teen's concerns.

autonomy vs shame and doubt

-1-3yrs -increased ability to control self and environment -practices and attains new physical skills, developing autonomy -symbolizes independence by controlling body secretions, saying no when asked to do something and directing motor activity -if successful, develops self-confidence and willpower; if criticized or unsuccessful, develops a sense of shame and doubt about his or her ability

Pre-operative

-2-7yrs -forms symbolic thought -exhibits egocentrism- unable to put oneself in the place of another -unable to understand conservation (clay, shapes, glasses of liquid, etc) -increasing ability to use language -play becomes more socialized -can concentrate on only one characteristic of an object at a time (centration)

initiative vs guilt

-3-6yrs -explores the physical world with all the senses, initiates new activities and considers new ideas -demonstrates initiative by being able to formulate and carry out a plan of action -develops conscience -if successful, develops direction and purpose; if criticized, leads to feelings of guilt and lack of purpose

trust vs mistrust

-birth-1ys -task of 1st yr is to establish trust in people providing care -mistrust develops if basic needs are inconsistently or inadequately met

AAP goals for prevention of childhood obesity 5-2-1-0

5 servings of fruits/veggies <2 hrs of screen time/day 1 hr or more of physical activity/day 0 sugared beverages

What is the key nursing role when managing the health care of a child living with a foster family? Determining if the child has mental health needs Advocating for the child and the services needed Securing proper educational placement Identifying any developmental delays

Advocating for the child and the services needed Explanation: Advocating for the child is the overarching nursing role. Unmet health needs are likely. Advocacy gives the child a "voice" so that the wide range of health care needs often prevalent in foster children can be met. Determining presence of mental health issues and developmental status as well as securing educational placement are specific issues among many that advocacy would address.

Why will it be necessary for the nurse to be very supportive of parents' attempts to feed the infant with recently repaired myelomeningocele? Pain will interfere with the feeding process. The infant will have a poor sucking reflex. Assuming the usual feeding position will be difficult. Nausea and vomiting often follow repair of the cystic mass.

Assuming the usual feeding position will be difficult. Explanation: Because the repaired area will need to be protected, having to use an alternate feeding position is likely. The infant may need to be fed prone with the head turned to the side and may not be able to be held. Being able to provide food for the infant is central to parenting the child. Difficulty nurturing a child can be very stressful. Little pain will be experienced and should easily be controlled owing to loss of sensation in the area. The sucking reflex should not be affected by the myelomeningocele or its repair. Nausea and vomiting are unlikely after recovery from the anesthetic.

A 12-year-old female client has been diagnosed with scoliosis with a curvature of 30 degrees. What type of treatment would the nurse anticipate being started on this client? Traction Bracing Exercise Surgery

Bracing Explanation: For spinal curvatures of 25 to 40 degrees, the usual treatment is bracing. Curvatures greater than 40 degrees may be treated with traction or spinal instrumentation and fusion. Exercise may be implemented for very mild curvatures to strengthen the back muscles.

Which of the following physical assessment findings would the physician be more likely to find in an examination of a client with Down syndrome than of other clients without Down syndrome? Hepatomegaly Congenital heart defects Diabetes mellitus Infertility

Congenital heart defects Explanation: Congenital heart defects are associated with Down syndrome. Hepatomegaly, infertility, and diabetes are not associated.

A 4-year-old adopted child has begun to ask questions about when she was born. Which suggestions by the clinic nurse would be considered the most appropriate answer for this child related to her birth? Select all that apply. Tell the child that her biological mom could not care for her after birth because she was HIV positive. Explain to the child that she grew inside another woman, but after the birth she was given to her adoptive mom and dad to raise. Avoid criticizing the biological parents but reinforce how much the adoptive mom and dad love them. Explain that her biological mom could not care for her so she was given away. Inform the child that her biological mom was in prison and would not be able to care for her for a long time.

Explain to the child that she grew inside another woman, but after the birth she was given to her adoptive mom and dad to raise. Avoid criticizing the biological parents but reinforce how much the adoptive mom and dad love them. Explanation: At least by 4 years, children are old enough to fully understand the story of their adoption: they grew inside the body of another woman who, because she could not care for them after they were born, gave them to the adopting parents to raise and love. It is important for parents not to criticize a birth mother as part of the explanation because children need to know, for their own self-esteem, that their birth parents were good people and they were capable of being loved by them, but things just did not work out that way. At age 4, children do not understand HIV status, not being able to provide for the needs of an infant, or prison terms.

The mother of a 3-year-old with a myelomeningocele is thinking about having another baby. The nurse should inform the woman that she should increase her intake of which acid? Folic acid to 0.4 mg/day Folic acid above 0.4 mg/day Ascorbic acid to 4 mg/day Ascorbic acid to 0.4 mg/day

Folic acid above 0.4 mg/day Explanation: The American Academy of Pediatrics recommends that a woman who has had a child with a neural tube defect increase her intake of folic acid to above 0.4 mg per day 1 month before becoming pregnant and continue this regimen through the first trimester. A woman who has no family history of neural tube defects should take 0.4 mg/day. All women of childbearing age should be encouraged to take a folic acid supplement because the majority of pregnancies in the United States are unplanned. Ascorbic acid hasn't been shown to have any effect on preventing neural tube defects.

Which condition is a part of normal newborn screening? Phenylketonuria Sickle cell anemia Cystic fibrosis Down syndrome

Phenylketonuria Explanation: Phenylketonuria is part of normal newborn screening. Prenatal screening includes Down syndrome. Preconception screening includes sickle cell anemia and cystic fibrosis.

The nursing instructor is teaching a session on the increase of health care costs associated with the advancement of modern technology. The instructor determines the session is successful when the students correctly choose which focus of community-based health care that has been implemented to combat the increased cost? Providing care for the client as an individual Keeping clients with chronic illnesses in their homes Preventing disease and its sequelae Tracking reportable diseases

Preventing disease and its sequelae Explanation: Community-based nursing focuses on prevention and is directed toward persons and families within a community. Community-based nursing is holistic in nature and provides care for the client as part of a family and community, not just as an individual. It strives to keep clients with chronic illnesses in their homes, but that is not the focus of the care provided. A function of community-based nursing is reporting and tracking reportable diseases; again, that is not the focus of community-based nursing.

The nurse caring for a woman in active labor notices a strange odor coming from some tea the family has brought. When questioned, the woman informs the nurse of herbs they have brewed in the tea to help lower the pain. Which intervention would be considered the most appropriate for the nurse to take? Research the herbs in the tea and report the findings to the provider. Ask the family to remove the tea from the L & D department. Inform the family that herbs and conventional drugs are not compatible. Suggest the woman rely solely on herbal prep rather than conventional medications.

Research the herbs in the tea and report the findings to the provider. Explanation: The nurse should be aware when taking health histories that many people today from all cultures rely on complementary or alternative therapies. Knowing about these is a way to be certain a medication that has been prescribed will not counteract or be synergistic with what herbs are being used. Asking the family to remove the tea from the facility is nontherapeutic. Telling the woman that she will have to rely on their herbal prep solely is not true unless the herbs are contradicted with conventional medicines. Unless research is done, making a blank statement that herbs and medications are incompatible is untrue

A woman in her third trimester has just learned that her fetus has been diagnosed with cri-du-chat syndrome. The nurse recognizes that this child will likely have which characteristic? cleft lip and palate small and nonfunctional ovaries an abnormal, cat-like cry rounded soles of the feet (rocker-bottom)

an abnormal, cat-like cry Explanation: Cri-du-chat syndrome is the result of a missing portion of chromosome 5. In addition to an abnormal cry, which sounds much more like the sound of a cat than a human infant's cry, children with cri-du-chat syndrome tend to have a small head, wide-set eyes, a downward slant to the palpebral fissure of the eye, and a recessed mandible. They are severely intellectually disabled. Rounded soles of the feet are characteristic of trisomy 18 syndrome. Cleft lip and palate are characteristic of trisomy 13 syndrome. Small and nonfunctional ovaries are characteristic of Turner syndrome.

A 14-year-old girl is diagnosed as having scoliosis. When doing scoliosis screening with her, an important observation would be to note: the posterior spine when she bends sideways. her posterior spine when she bends forward. the angle of the iliac crest when she bends forward. the angle of her lower chest when she sits down.

her posterior spine when she bends forward. Explanation: A lateral curvature of the spine (scoliosis) is best revealed when the child bends forward. Bending to the side would not provide an accurate assessment of the spine nor would assessing the iliac crest or the chest.

A nurse doing an admission assessment on a new Chinese American client notices that the client will not make eye contact. The most likely reason for this is that it: implies the client is not interested. is a sign of disrespect. implies the client wants to avoid the nurse. is a sign of respect.

is a sign of respect. Explanation: Whether people look at one another when talking is culturally determined. Chinese Americans, for example, may not make eye contact during a conversation. This social custom shows respect for the position of the health care provider and is a compliment and not an avoidance issue.

A Native American mother has just arrived in the L & D department in active labor. Following the birth, which cultural practice may the nurse help arrange? allowing the elders of the tribe to stay, round-the-clock, in her room for protection from evil spirits allowing incense to burn in the mother's room as part of her "rooming-in" ritual allowing no one to touch the baby's head for the first 24 hours post birth making arrangements for the mother to take home placenta after the birth

making arrangements for the mother to take home placenta after the birth Explanation: An example of implementing care might be to make arrangements for a new Native American mother to take home the placenta after birth of her child if that is important to her. Touching the head is offensive in many Middle Eastern societies. Elders of the tribe do not stay with the mother throughout the hospitalization. All hospitals have a strict law against open flames from candles or incense, so an exception is not allowed.

The nurse is caring for a 2-year-old boy with cerebral palsy (CP). The medical record indicates "hypertonicity and permanent contractures affecting both extremities on one side." Based on these findings, the nurse identifies this type of CP as: spastic. athetoid or dyskinetic. mixed. ataxic.

spastic. Explanation: Spastic involves hypertonicity and permanent contractures on both extremities on one side. Athetoid (dyskinetic) involves abnormal involuntary movements affecting all four extremities and sometimes the face, neck, and tongue. Ataxic affects balance and depth perception. Spastic affects the lower extremities. Mixed is a combination of spastic, athetoid and ataxic.

A nurse is providing home care to a pregnant woman who is on bed rest. The woman has two other children. During her assessment, the nurse asks the woman how she occupies her time. What is the best rationale for asking this question? to build rapport with the client to pick up tips to pass on to other clients who are on bed rest to learn about the client's hobbies to ensure that the woman is not engaging in activities that would disrupt her rest

to ensure that the woman is not engaging in activities that would disrupt her rest Explanation: If bed rest is required, ask how the client occupies her time. A woman is not really resting if she is concerned about her family or finances, is caring for older children, or is so bored that she is frequently turning or sitting up. The other answers are legitimate reasons for asking the question but are not the best rationale for it.