Question

A nurse is teaching the parents of an infant with cerebral palsy on how to provide optimal care. What should the nurse include in the teaching?

Answer 1

Correct Answers:

Preserve muscle tone to prevent joint contractures

Rationale :

🦵Cerebral palsy often results in muscle stiffness and joint contractures due to spasticity. To prevent this, maintaining muscle tone is essential, as it helps prevent deformities and encourages proper mobility.

🦵The goal of therapy in cerebral palsy includes maintaining range of motion, which can reduce contractures and allow better functional movement.

🦵Splints may be used, but they don’t replace active interventions aimed at improving muscle tone.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 2

Correct Answers:

Encourage the child to feed himself finger foods

Rationale :

🧸 At 18 months, the toddler is in Erikson’s autonomy vs. shame and doubt stage and should be encouraged to develop independence.

🧸 Feeding themselves finger foods promotes motor development and self-efficacy.

🧸 Toddlers engage in parallel play, not group games .

🧸 Walking alone without supervision may be unsafe, and excessive cuddling may discourage autonomy.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 3

Correct Answers:

"The big soft spot is usually closed between 12 and 18 months of age

Rationale :

🧠 The anterior fontanel typically closes between 12–18 months as the cranial bones ossify.

🧠 Closure at 2 months refers to the posterior fontanel.

🧠 While fontanel closure can vary slightly, is too vague and not helpful.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 4

Correct Answers:

CD4-T-cell count 180 cells/mm

Rationale :

🦠 CD4 count below 200 cells/mm³ indicates severe immunosuppression and risk for opportunistic infections.

🦠 Positive Western blot confirms diagnosis but is not urgent.

🦠 Platelets and WBC are normal or not critical here.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 5

Correct Answers:

Arrange a multi-disciplinary team meeting, including the teenager and his family to discuss the situation and set goals together

Rationale :

🧑‍🤝‍🧑 Adolescents are in Erikson’s stage of identity vs. role confusion, where control and independence are crucial to their psychosocial development—even when facing terminal illness.

🧑‍🤝‍🧑 A multidisciplinary meeting that includes the teenager, their family, and healthcare professionals helps ensure that care is collaborative, respectful, and centered on the teen's goals and preferences.

🧑‍🤝‍🧑 This approach acknowledges the adolescent’s need for autonomy and provides emotional validation during a challenging time.

🧑‍🤝‍🧑 Alternatives like simply distracting the teen or emphasizing compliance fail to address his psychological, social, and developmental needs, which are especially important in palliative care settings.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 6

Correct Answers:

Encourage the client to complete school work

Rationale :

📚 Children around 10 years of age are in Erikson’s stage of industry vs. inferiority, where success and achievement are key to developing self-esteem.

📚 Engaging in schoolwork promotes a sense of normalcy, purpose, and productivity, even during hospitalization.

📚 It also helps maintain cognitive development and keeps the child on track academically.

📚 Denying schoolwork or social connection may lead to feelings of inferiority and detachment from peers and responsibilities.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 7

Correct Answers:

Fever
Unwillingness to move affected extremity
Severe pain

Rationale :

🌡️ Fever

🌡️ Fever is one of the earliest systemic signs of infection in children with osteomyelitis.

🌡️ The body's immune system responds to the bone infection by raising the temperature to fight off invading organisms.

🌡️ This helps differentiate osteomyelitis from non-infectious causes of limb pain or swelling.

🌡️ In pediatric clients, fever may be high-grade and persistent, signaling active inflammation.

🚫 Unwillingness to move affected extremity

Rationale:

🚫 Children with osteomyelitis often guard or refuse to move the infected limb due to significant pain and swelling.

🚫 This is referred to as pseudoparalysis, where the child avoids movement without actual paralysis.

🚫 The limited mobility is protective and may be mistaken for muscle or nerve injury, making careful assessment crucial.

🚫 This symptom often appears before visible swelling or redness, especially in deep bone infections.

🔴 Redness and swelling at the site

🔴 Local inflammation is a hallmark sign of osteomyelitis, particularly in superficial bones or advanced stages.

🔴 Swelling and erythema occur due to inflammatory cell infiltration and pus formation.

🔴 The affected limb may also be warm to the touch, and surrounding tissues may become edematous and tense.

🔴 This finding supports the diagnosis of acute osteomyelitis and requires prompt antibiotic therapy.

⚡ Severe pain

⚡ Osteomyelitis leads to deep, localized bone pain that is often not relieved by routine analgesics.

⚡ Pain results from increased intramedullary pressure as pus and inflammation expand within the bone.

⚡ The child may cry when the area is touched or manipulated and may avoid weight-bearing if the lower limbs are involved.

⚡ This pain is usually out of proportion to superficial signs, making it a critical diagnostic clue.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 8

Correct Answers:

Monitor for increased temperature

Rationale :

🌡️ After VP (ventriculoperitoneal) shunt insertion, infection is the most concerning complication, and fever is often the first sign.

🌡️ Monitoring for temperature spikes helps detect meningitis or shunt infections early.

🌡️ Treating fever promptly may prevent further neurological damage.

🌡️ Routine testing of CSF or urine is not part of standard postoperative monitoring unless there are specific concerns.

🌡️ Pain medication is important but must not mask signs of systemic infection.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 9

Correct Answers:

2

Rationale :

🧮 The prescribed dose is 0.175 mg, which converts to 175 micrograms (mcg).

🧮 The available strength is 88 mcg per tablet.

🧮 Using the formula:

175 ÷ 88 = 1.99, which rounds to 2 tablets.

🧮 It’s important to round to the nearest whole number and avoid trailing zeros per medication safety guidelines.

🧮 Accurate dose calculation prevents both underdosing and overdosing, especially in endocrine therapies.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 10

Correct Answers:

Hyperipidemia
Hypoproteinemia

Rationale :

🧬 Hyperlipidemia

🧬 Nephrotic syndrome leads to severe protein loss in urine (proteinuria), which causes the liver to compensate by increasing lipid synthesis.

🧬 As a result, blood levels of cholesterol and triglycerides rise, resulting in hyperlipidemia.

🧬 This mechanism is part of the body’s attempt to restore oncotic pressure in the bloodstream after losing albumin.

🧬 Hyperlipidemia contributes to long-term cardiovascular risks if left unmanaged, making lipid monitoring essential.

🧪 Hypoproteinemia

🧪 Hypoproteinemia in nephrotic syndrome occurs due to massive urinary protein loss, primarily albumin, from damaged glomeruli.

🧪 The low blood protein level leads to decreased oncotic pressure, which contributes to edema, a key feature of the condition.

🧪 Despite normal or increased protein intake, loss exceeds synthesis, especially in children.

🧪 Low protein levels affect nutritional status, immune response, and fluid balance, requiring prompt correction.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

QLexNursing

1 :
A nurse is teaching the parents of an infant with cerebral palsy on how to provide optimal care. What should the nurse include in the teaching?

2 :
The nurse is planning care for an 18 month-old child. Which of the following should be included in the child's care?

3 :
The nervous parent asks when the big "soft spot" (anterior fontanel) will be closed. The nurse's most informative response would be

4 :
A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority?

6 :
A nurse is planning care for a 10-year-old child who will be hospitalized for an extended period of time. Which of the following at the nurse include in the plan of care to meet the client's psychosocial needs according to Erikson?

7 :
Which would the nurse assess in a child diagnosed with osteomyelitis? Select all that apply.

8 :
Which action should the nurse take when providing postoperative nursing care to a child after insertion of ventriculoperitone (VP) shunt?

9 :
A nurse is preparing to administer levothyroxine 0.175 mg PO once a day. The amount available is levothyroxine 88 mcg/tablet. How many tablets should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero)

10 :
The nurse anticipates that there will be two classic hematologic characteristics in the blood chemistry of a child with nephrotic syndrome which are: (Select all that apply.)

QLexNursing

1 : A nurse is teaching the parents of an infant with cerebral palsy on how to provide optimal care. What should the nurse include in the teaching?

2 : The nurse is planning care for an 18 month-old child. Which of the following should be included in the child's care?

3 : The nervous parent asks when the big "soft spot" (anterior fontanel) will be closed. The nurse's most informative response would be

4 : A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority?

6 : A nurse is planning care for a 10-year-old child who will be hospitalized for an extended period of time. Which of the following at the nurse include in the plan of care to meet the client's psychosocial needs according to Erikson?

7 : Which would the nurse assess in a child diagnosed with osteomyelitis? Select all that apply.

8 : Which action should the nurse take when providing postoperative nursing care to a child after insertion of ventriculoperitone (VP) shunt?

9 : A nurse is preparing to administer levothyroxine 0.175 mg PO once a day. The amount available is levothyroxine 88 mcg/tablet. How many tablets should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero)

10 : The nurse anticipates that there will be two classic hematologic characteristics in the blood chemistry of a child with nephrotic syndrome which are: (Select all that apply.)

1 :
A nurse is teaching the parents of an infant with cerebral palsy on how to provide optimal care. What should the nurse include in the teaching?

2 :
The nurse is planning care for an 18 month-old child. Which of the following should be included in the child's care?

3 :
The nervous parent asks when the big "soft spot" (anterior fontanel) will be closed. The nurse's most informative response would be

4 :
A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority?

6 :
A nurse is planning care for a 10-year-old child who will be hospitalized for an extended period of time. Which of the following at the nurse include in the plan of care to meet the client's psychosocial needs according to Erikson?

7 :
Which would the nurse assess in a child diagnosed with osteomyelitis? Select all that apply.

8 :
Which action should the nurse take when providing postoperative nursing care to a child after insertion of ventriculoperitone (VP) shunt?

9 :
A nurse is preparing to administer levothyroxine 0.175 mg PO once a day. The amount available is levothyroxine 88 mcg/tablet. How many tablets should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero)

10 :
The nurse anticipates that there will be two classic hematologic characteristics in the blood chemistry of a child with nephrotic syndrome which are: (Select all that apply.)