Question

A home health nurse is doing the first intake visit for a child who has hemiplegic cerebral palsy. When developing a plan of care for this child, which of the following goals is the priority for the nurse to include in the plan of care?

Answer 1

Correct Answers:

Modify the home for safety

Rationale :

🏠 Children with hemiplegic cerebral palsy have motor impairments on one side of the body, increasing the risk of falls, injury, and mobility limitations.

🏠 Environmental safety is the priority to prevent injuries and promote independence within the child’s current functional level.

🏠 Modifications may include grab bars, non-slip flooring, corner padding, and wheelchair/walker access as needed.

🏠 While assisting with ADLs and offering parent respite are important, safety and injury prevention take precedence.

🏠 Safety adaptations are part of early intervention to maximize developmental outcomes in cerebral palsy.

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Answer 2

Correct Answers:

Apply direct pressure at the site and one inch above the catheterization site

Rationale :

🩸 A soaked dressing and bed following arterial catheterization is a sign of active, potentially life-threatening bleeding.

🩸 The first priority is to stop the bleeding by applying direct pressure, including pressure above the puncture site to compress the artery.

🩸 Arterial bleeding can cause rapid blood loss; delaying pressure increases the risk of hypovolemic shock.

🩸 Notification of the provider should come after initial bleeding control is achieved.

🩸 Trendelenburg positioning is not appropriate and may worsen bleeding in arterial sites.

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Answer 3

Correct Answers:

Immediately report this finding as this is life threatening

Rationale :

🚨 No drainage from chest tubes for 2 hours after open heart surgery may indicate tamponade or obstruction, both are surgical emergencies.

🚨 The nurse must immediately notify the provider, as fluid may be accumulating in the pericardial space, compressing the heart.

🚨 Tamponade presents with signs like hypotension, muffled heart sounds, and poor perfusion, and requires urgent intervention.

🚨 This is not expected and should never be documented as normal postoperatively.

🚨 Coughing or positioning may be used for minor blockages after physician notification, not as first actions.

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Answer 4

Correct Answers:

"Would you like to talk about your decision and discuss alternatives?"

Rationale :

🧠 The nurse’s role is to support parental decision-making while exploring adaptive and inclusive options for the child.

🧠 This response opens dialogue without judgment, allowing the nurse to assess emotional impact, concerns, and needs.

🧠 It is non-directive and promotes shared problem-solving and empowerment of the family.

🧠 Sports can often be adapted (e.g., wheelchair baseball or inclusive leagues), and assumptions should not be made.

🧠 Dismissive or affirming responses without understanding the reasoning can alienate parents or dismiss the child’s abilities.

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Answer 5

Correct Answers:

Treatment for strep throat within the last two weeks

Rationale :

🧫 Post-streptococcal glomerulonephritis (PSGN) is a known sequela of group A beta-hemolytic streptococcus (GABHS) infections.

🧫 It typically develops 1–2 weeks after an untreated or recent strep throat infection.

🧫 PSGN is caused by immune complex deposition in the glomeruli, leading to hematuria, proteinuria, and edema.

🧫 Runny nose/itchy eyes suggest allergies, not strep. Viral illness or UTI history is not linked to glomerulonephritis.

🧫 Prompt recognition leads to early management of potential renal complications.

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Answer 6

Correct Answers

Monitor RLE pulses with vital signs [ Anticipated ]
Administer Oxycodone 3 mg Q3-4 hours PRN for pain [ Anticipated ]
Continue IV NSS bolus @ 67 ml/hour [ Anticipated ]
Decrease 02 to 2 L/min [ Contraindicated ]

Rationale :

✅ 1. Monitor RLE pulses with vital signs — Anticipated

🦵 In a vaso-occlusive crisis (VOC), pain and inflammation are commonly localized in the long bones or joints, as seen here in the right lower extremity (RLE).

🦵 Monitoring distal pulses ensures that tissue perfusion remains intact and helps detect early signs of compartment syndrome or severe ischemia.

🦵 Although the RLE is warm, tender, and pulse strength is currently intact, VOC can worsen rapidly and monitoring is critical.

🦵 Including RLE pulse checks with routine vital signs helps track changes and ensure timely response to perfusion threats.

🦵 Neurovascular assessment is essential, especially in the context of repeated VOCs or increasing severity, as reported by the parent.

✅ 2. Administer Oxycodone 3 mg Q3–4 hours PRN for pain — Anticipated

💊 Severe pain is the hallmark of a vaso-occlusive crisis due to ischemia from sickled red cells occluding vessels.

💊 The child’s pain rating is 10/10 using the FACES scale, indicating the need for effective analgesia.

💊 The child uses oxycodone at home and received 3 mg PO in the ER, demonstrating it is a safe and established regimen.

💊 PRN dosing every 3–4 hours is appropriate for breakthrough pain management and aligns with the child’s chronic pain regimen.

💊 Prompt and adequate pain control also reduces physiologic stress, improves oxygenation, and minimizes complications.

✅ 3. Continue IV NSS @ 67 mL/hour — Anticipated

💧 Hydration is a cornerstone treatment in VOC to reduce blood viscosity and improve circulation of red blood cells.

💧 The child was already started on a 20 mL/kg bolus followed by maintenance fluids at 67 mL/hr, based on weight.

💧 Continued IV fluid administration promotes rehydration and helps prevent further sickling of RBCs.

💧 Normal saline is preferred for hydration in sickle cell patients because it does not contain glucose, which could worsen dehydration.

💧 Care must be taken to avoid fluid overload, but maintenance hydration at this rate is standard.

❌ 4. Decrease O₂ to 2 L/min — Contraindicated

🫁 The child is in active VOC with pain, increased respiratory rate, and hypoxia risk, and is already receiving O₂ at 4 L/min via nasal cannula.

🫁 Oxygen administration helps reduce hypoxia-induced sickling, especially during crises.

🫁 Decreasing oxygen too early may exacerbate sickling and compromise tissue oxygen delivery.

🫁 Since the child is in distress and had ongoing respiratory signs (e.g., shallow breathing, high pain level), oxygen must be maintained until clinical improvement and labs confirm stability.

🫁 Tapering oxygen should be guided by O₂ saturation levels, respiratory assessment, and MD orders — not done preemptively.

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Answer 7

Correct Answers:

Lumbar puncture

Rationale :

🧠 Neuroblastoma is a cancer that originates in neural crest cells and often spreads to the central nervous system (CNS).

🧠 A lumbar puncture (LP) helps determine CNS involvement, particularly metastasis to the cerebrospinal fluid (CSF).

🧠 This test is critical when staging the disease to guide treatment planning, especially for advanced stages.

🧠 Other tests like CT scans or biopsies confirm the location and type, but LP assesses spread to CNS specifically.

🧠 Early identification of metastasis improves the ability to tailor therapy and monitor prognosis.

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Answer 8

Correct Answers:

An apical pulse of 70 beats/minute and vomiting

Rationale :

❤️ Digoxin toxicity is a critical concern in children, especially when signs such as bradycardia (HR of 70) and vomiting are present.

❤️ In children, vomiting without other symptoms may be the earliest sign of digoxin toxicity.

❤️ Normal heart rate in a 3-year-old is above 90 bpm; 70 bpm is dangerously low and warrants immediate intervention.

❤️ The use of furosemide can cause hypokalemia, which increases the risk of digoxin toxicity.

❤️ This combination of symptoms suggests a cardiac emergency, requiring lab work and possible digoxin level evaluation.

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Answer 9

Correct Answers:

Prone with hips flexed and legs abducted

Rationale :

🛏️ In infants with myelomeningocele, placing the baby prone (on the stomach) helps prevent rupture of the sac.

🛏️ Flexing the hips and abducting the legs minimizes tension on the spinal defect and supports comfort.

🛏️ Supine or side-lying positions are contraindicated, as they can put direct pressure on the sac, increasing the risk of infection or damage.

🛏️ Keeping the area clean, moist, and protected is essential until surgical closure.

🛏️ The nurse must also monitor for CSF leakage and signs of infection around the sac.

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Answer 10

Correct Answers:

1400: Basketball practice, dizzy no loss of consciousness, no caffeine today.

Rationale :

📋 A Holter monitor diary must document activity, symptoms, time, and possible triggers for proper correlation with ECG changes.

📋 Entry B includes the time, activity (basketball), symptom (dizziness), response (no LOC), and diet (no caffeine) — which are all relevant.

📋 This allows the healthcare team to match symptoms with cardiac rhythm changes on the monitor.

📋 Entry A contains vital signs but lacks context; C and D are incomplete or irrelevant.

📋 Accurate diaries help diagnose arrhythmias, syncope causes, or exertional symptoms.

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Options	Anticipated	Contraindicated
Monitor RLE pulses with vital signs
Administer Oxycodone 3 mg Q3-4 hours PRN for pain
Continue IV NSS bolus @ 67 ml/hour
Decrease 02 to 2 L/min

QLexNursing

1 :
A home health nurse is doing the first intake visit for a child who has hemiplegic cerebral palsy. When developing a plan of care for this child, which of the following goals is the priority for the nurse to include in the plan of care?

2 :
The nurse is caring for a school-age girl who had an arterial cardiac catheterization. The child tells the nurse that the bandage is "wet." On assessment, the bandage and bed are soaked with blood. The nurse must do which of the following FIRST?

3 :
The nurse is caring for a preschool aged child immediately following an open repair of a Ventricular Septal Defect. There has been no drainage from the mediastinal chest tubes in the last 2 hours. Based on this finding what will be the nurse's priority intervention?

4 :
A nurse is speaking with the parents of a 4-year-old boy who has a cerebral palsy. The parents tell the nurse they have taken their son's name off the list for baseball next season. Which of the following is the BEST response for the nurse to make?

5 :
A school aged child is being evaluated for possible glomerulonephritis. During the physical exam the nurse recognizes that which of the following, is a possible cause?

6 :
The nurse is admitting a 6-year-old child with Sickle Cell Anemia who is being admitted for vaso-occlusive crisis.

Correct Answers

7 :
A 2-year-old child is diagnosed with neuroblastoma. The nurse understands that which of the following tests help to determine the extent of tumor metastasis?

8 :
A 3-year-old child with congestive heart failure resulting from an underlying congenital heart defect, is prescribed digoxin and furosemide. Which of the following assessment findings are MOST concerning?

9 :
The nurse understands that in the preoperative period the infant with a myelomeningocele must be placed in which of the following positions?

10 :
The nurse is reviewing 24-hour Holter monitor diaries of various patients. Which of the following entries is the MOST complete?

QLexNursing

1 : A home health nurse is doing the first intake visit for a child who has hemiplegic cerebral palsy. When developing a plan of care for this child, which of the following goals is the priority for the nurse to include in the plan of care?

2 : The nurse is caring for a school-age girl who had an arterial cardiac catheterization. The child tells the nurse that the bandage is "wet." On assessment, the bandage and bed are soaked with blood. The nurse must do which of the following FIRST?

3 : The nurse is caring for a preschool aged child immediately following an open repair of a Ventricular Septal Defect. There has been no drainage from the mediastinal chest tubes in the last 2 hours. Based on this finding what will be the nurse's priority intervention?

4 : A nurse is speaking with the parents of a 4-year-old boy who has a cerebral palsy. The parents tell the nurse they have taken their son's name off the list for baseball next season. Which of the following is the BEST response for the nurse to make?

5 : A school aged child is being evaluated for possible glomerulonephritis. During the physical exam the nurse recognizes that which of the following, is a possible cause?

6 : The nurse is admitting a 6-year-old child with Sickle Cell Anemia who is being admitted for vaso-occlusive crisis.

Correct Answers

7 : A 2-year-old child is diagnosed with neuroblastoma. The nurse understands that which of the following tests help to determine the extent of tumor metastasis?

8 : A 3-year-old child with congestive heart failure resulting from an underlying congenital heart defect, is prescribed digoxin and furosemide. Which of the following assessment findings are MOST concerning?

9 : The nurse understands that in the preoperative period the infant with a myelomeningocele must be placed in which of the following positions?

10 : The nurse is reviewing 24-hour Holter monitor diaries of various patients. Which of the following entries is the MOST complete?

1 :
A home health nurse is doing the first intake visit for a child who has hemiplegic cerebral palsy. When developing a plan of care for this child, which of the following goals is the priority for the nurse to include in the plan of care?

2 :
The nurse is caring for a school-age girl who had an arterial cardiac catheterization. The child tells the nurse that the bandage is "wet." On assessment, the bandage and bed are soaked with blood. The nurse must do which of the following FIRST?

3 :
The nurse is caring for a preschool aged child immediately following an open repair of a Ventricular Septal Defect. There has been no drainage from the mediastinal chest tubes in the last 2 hours. Based on this finding what will be the nurse's priority intervention?

4 :
A nurse is speaking with the parents of a 4-year-old boy who has a cerebral palsy. The parents tell the nurse they have taken their son's name off the list for baseball next season. Which of the following is the BEST response for the nurse to make?

5 :
A school aged child is being evaluated for possible glomerulonephritis. During the physical exam the nurse recognizes that which of the following, is a possible cause?

6 :
The nurse is admitting a 6-year-old child with Sickle Cell Anemia who is being admitted for vaso-occlusive crisis.

7 :
A 2-year-old child is diagnosed with neuroblastoma. The nurse understands that which of the following tests help to determine the extent of tumor metastasis?

8 :
A 3-year-old child with congestive heart failure resulting from an underlying congenital heart defect, is prescribed digoxin and furosemide. Which of the following assessment findings are MOST concerning?

9 :
The nurse understands that in the preoperative period the infant with a myelomeningocele must be placed in which of the following positions?

10 :
The nurse is reviewing 24-hour Holter monitor diaries of various patients. Which of the following entries is the MOST complete?