Chapter 30 - QUIZ
The nurse should suspect a child has cerebral palsy (CP) if the parent says what?
"My 4-month-old doesn't lift his head when on his tummy."
The parents of an infant with cerebral palsy (CP) ask the nurse if their child will have cognitive impairment. The nurse's response should be based on which knowledge?
About 45% of affected children have normal intelligence.
What statement is most accurate in describing tetanus?
Acute infectious disease caused by an exotoxin produced by an anaerobic spore-forming, gram-positive bacillus.
What functional ability should the nurse expect in a child with a spinal cord lesion at C7?
Almost complete independence within limitations of wheelchair
What is the most common cause of cerebral palsy (CP)?
Cerebral trauma
The nurse is preparing a staff education in-service session for a group of new graduate nurses who will be working in a long-term care facility for children; many of the children have cerebral palsy (CP). What statement should the nurse include in the training?
Children with spastic pyramidal CP have a positive Babinski sign and ankle clonus.
An adolescent has just been brought to the emergency department with a spinal cord injury and paralysis from a diving accident. The parents keep asking the nurse, "How bad is it?" The nurse's response should be based on which knowledge?
Extent and severity of damage cannot be determined for several weeks or even months.
A recommendation to prevent neural tube defects (NTDs) is the supplementation of what?
Folic acid for all women of childbearing age
The nurse is caring for a family whose infant was just born with anencephaly. What is the most important nursing intervention?
Help the family cope with the birth of an infant with a fatal defect.
Spastic cerebral palsy (CP) is characterized by which clinical manifestations?
Hypertonicity; poor control of posture, balance, and coordinated motion
During a well-child visit, the mother tells the nurse that her 4-month-old infant is constipated, is less active than usual, and has a weak-sounding cry. The nurse suspects botulism and questions the mother about the child's diet. What factor should support this diagnosis?
Infant cereal with honey
A 4-month-old with significant head lag meets the criteria for floppy infant syndrome. A diagnosis of progressive infantile spinal muscular atrophy (Werdnig-Hoffmann disease) is made. What should be included in the nursing care for this child?
Infant stimulation program
What statement best describes Duchenne (pseudohypertrophic) muscular dystrophy (DMD)?
It is characterized by presence of Gower sign, a waddling gait, and lordosis.
Gingivitis is a common problem in children with cerebral palsy (CP). What preventive measure should be included in the plan of care?
Meticulous dental hygiene
A 14-year-old girl is in the intensive care unit after a spinal cord injury 2 days ago. What nursing intervention is a priority for this child?
Monitoring and maintaining systemic blood pressure
An 8-year-old child is hospitalized with infectious polyneuritis (Guillain-Barré syndrome [GBS]). When explaining this disease process to the parents, what should the nurse consider?
Muscle strength slowly returns, and most children recover.
An adolescent with a spinal cord injury is admitted to a rehabilitation center. Her parents describe her as being angry, hostile, and uncooperative. The nurse should recognize that this is suggestive of which psychosocial state?
Normal response to her situation that can be redirected in a healthy way
The nurse is caring for a 4-year-old child with cerebral palsy (CP). The child, developmentally, is at an infant stage. Appropriate developmental stimulation for this child should be what?
Putting a colorful mobile with music on the bed
What is a major goal of therapy for children with cerebral palsy (CP)?
Recognize the disorder early and promote optimum development.
An 8-year-old girl with moderate cerebral palsy (CP) recently began joining a regular classroom for part of the day. Her mother asks the school nurse about joining the after-school Girl Scout troop. The nurse's response should be based on which knowledge?
Recreational activities often provide children with CP with opportunities for socialization and recreation.
What type of cerebral palsy (CP) is the most common type?
Spastic
A child, age 3 years, has cerebral palsy (CP) and is hospitalized for orthopedic surgery. His mother says he has difficulty swallowing and cannot hold a utensil to feed himself. He is slightly underweight for his height. What is the most appropriate nursing action related to feeding this child?
Stabilize his jaw with caregiver's hand (either from a front or side position) to facilitate swallowing.
A 12-year-old child with Guillain-Barré syndrome (GBS) is admitted to the pediatric intensive care unit. She tells you that yesterday her legs were weak and that this morning she was unable to walk. After the nurse determines the current level of paralysis, which should the next priority assessment be?
Swallowing ability
An adolescent whose leg was crushed when she fell off a horse is admitted to the emergency department. She has completed the tetanus immunization series, receiving the last tetanus toxoid booster 8 years ago. What care is necessary for therapeutic management of this adolescent to prevent tetanus?
Tetanus toxoid booster is needed because of the type of injury.
