Question

A nurse is developing a teaching plan for nutrition, for parents of a 4-year-old child diagnosed with cerebral palsy. Which of the following statements made by the parent demonstrate a good understanding of the teaching? SELECT ALL THAT APPLY "I will:

Answer 1

Correct Answers:

hold my child's cheeks together when chewing to provide stability of the mouth.
provide my child with adaptive utensils to assist with eating."

Rationale :

🍽️Hold my child’s cheeks together when chewing to provide stability of the mouth.

🍽️ Children with cerebral palsy (CP) often have poor muscle tone or spasticity that affects the muscles used for chewing and swallowing.

🍽️ By gently holding the cheeks together, the parent helps the child maintain proper jaw alignment and lip closure, making it easier to chew and swallow safely.

🍽️ This also helps reduce the risk of choking or aspiration and encourages better control of food within the mouth.

🍽️ It’s a supportive action that promotes safe feeding and improved oral motor coordination.

🥄 Provide my child with adaptive utensils to assist with eating.

🥄 Adaptive utensils—such as angled spoons, large-handled forks, or plates with raised edges—help children with CP who have limited motor control or coordination difficulties.

🥄 These tools encourage greater independence during meals by making it easier to grasp, scoop, and bring food to the mouth.

🥄 Adaptive equipment is part of promoting self-feeding skills, enhancing confidence, and fostering developmental progress in daily activities.

🥄 Occupational therapists often help families select and train the use of these utensils for optimal results.

😌 Maintain my child's mouth in a normal position from the side of their face.

😌 Proper head and mouth positioning is crucial for safe feeding in children with cerebral palsy.

😌 Supporting the child’s jaw from the side of the face helps maintain alignment, promotes effective swallowing, and reduces the risk of aspiration.

😌 The “normal position” refers to slight chin tuck with a neutral head—not tilted backward—which helps control food flow and swallowing safety.

😌 This physical support also assists in developing proper oral-motor patterns during feeding.

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Answer 2

Correct Answers:

Salicylate (Aspirin)

Rationale :

💊 Kawasaki disease is an acute, systemic vasculitis that primarily affects children under 5 years old and can lead to coronary artery aneurysms if untreated.

💊 The primary treatment includes high-dose intravenous immunoglobulin (IVIG) and salicylate (aspirin) therapy.

💊 Aspirin is used for its anti-inflammatory effects during the acute phase and antiplatelet effects during the subacute phase to prevent thrombus formation in the coronary arteries.

💊 This medication must be given carefully under supervision due to the risk of Reye’s syndrome, but its benefits outweigh the risks in this specific disease.

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Answer 3

Correct Answers:

Walks with legs planted widely apart

Rationale :

🧠 A wide-based gait is an early sign of cerebral palsy (CP), particularly the spastic type, where muscle stiffness and poor coordination affect walking and balance.

🧠 These children may also show delayed motor milestones, asymmetric movements, or scissoring of legs when supported upright.

🧠 The wide stance is a compensatory mechanism for poor balance and weak muscle control.

🧠 Other signs include persistence of primitive reflexes and abnormal muscle tone (hypertonia or hypotonia).

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Answer 4

Correct Answers:

Change diapers frequently
Remove soiled diapers promptly
Use non-irritant cleanser wipes

Rationale :

👶 B. Change diapers frequently

👶 Frequent diaper changes are one of the most effective strategies to prevent diaper dermatitis because they minimize prolonged exposure to moisture, friction, and irritants from urine and stool.

👶 Keeping the skin dry helps maintain its natural barrier function, reducing the likelihood of inflammation and maceration (softening of skin due to moisture).

👶 Parents should be taught to check the diaper every 2–3 hours and immediately after the child has urinated or had a bowel movement.

👶 Frequent diaper changes also help detect early redness or irritation so that barrier creams (like zinc oxide) can be applied preventively.

🧴 D. Remove soiled diapers promptly

🧴 Prompt removal of soiled diapers prevents skin contact with ammonia, digestive enzymes, and bacteria, which can break down delicate infant skin.

🧴 Stool enzymes, especially in breastfed infants, are highly irritating to the skin and can accelerate inflammatory breakdown, leading to dermatitis.

🧴 Quick diaper removal, followed by gentle cleansing and air drying, helps maintain hygiene and decreases the risk of secondary infections like Candida albicans.

🧴 Parents should keep clean diapers and wipes nearby to make changes convenient and timely.

🌿 E. Use non-irritant cleanser wipes

🌿 Gentle, fragrance-free, and alcohol-free wipes or cleansers should be used when cleaning the diaper area.

🌿 Harsh wipes containing perfumes, alcohol, or antibacterial agents can strip the skin’s protective oils, increasing irritation and dryness.

🌿 Non-irritant cleansers maintain skin pH balance, reducing inflammation and protecting against further damage.

🌿 For infants with very sensitive skin, plain warm water with a soft cloth can be used instead of wipes to avoid irritation altogether.

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Answer 5

Correct Answers:

Monitoring oral temperature every 4 hours

Rationale :

🦵 The Ilizarov external fixator is a skeletal device used to stabilize fractures or correct bone deformities. It involves metal pins or wires that pierce the skin and bone, creating a direct pathway for infection to enter the body.

🦵 Because of this, infection prevention and early detection are the top nursing priorities. Monitoring the child’s temperature every 4 hours helps detect the first sign of systemic infection, such as osteomyelitis or pin-site infection.

🦵 The nurse should also perform frequent pin-site assessments for redness, swelling, drainage, or tenderness and report any abnormalities immediately.

🦵 Although nutrition, bowel sounds, and activity are important, they are not as critical as early infection detection, which can have serious complications if missed.

🦵 A low-grade fever might be the first clue to a developing infection—timely recognition allows for prompt intervention and prevents long-term damage to the bone or systemic sepsis.

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Answer 6

Correct Answers:

Limit care to essentials such as mouth care

Rationale :

💠 When death is imminent, the nurse’s goal is to promote comfort and dignity, not prolong procedures or cause unnecessary distress.

💠 Limiting care to essentials, such as mouth care, gentle repositioning, and maintaining skin integrity, helps keep the child comfortable and prevents discomfort from invasive or unnecessary interventions.

💠 Vital signs and routine assessments are discontinued, as they no longer contribute to comfort.

💠 The environment should remain quiet, calm, and soothing, allowing the family to spend peaceful time with the child.

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Answer 7

Correct Answers:

Factor VIII Concentrate

Rationale :

💎 Hemophilia A results from a deficiency of clotting factor VIII, which is essential for normal blood coagulation. When a child develops hemarthrosis (bleeding into a joint), the immediate priority is to replace the missing factor to stop bleeding and prevent joint damage.

💎 Factor VIII concentrate is the treatment of choice, as it directly corrects the deficiency and allows the body to form a stable clot.

💎 Administration should occur as soon as possible, often before diagnostic procedures or physical therapy.

💎 After factor replacement, RICE therapy (Rest, Ice, Compression, Elevation) may be applied to reduce swelling and pain in the affected joint.

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Answer 8

Correct Answers:

weekly serial casting changes with manipulation."

Rationale :

🔶 The initial treatment for congenital clubfoot (talipes equinovarus) involves gentle manipulation and weekly serial casting, usually starting shortly after birth.

🔶 This process, known as the Ponseti method, gradually moves the foot into the correct position through repeated stretching and recasting every 1–2 weeks.

🔶 Once proper alignment is achieved, additional interventions such as heel cord (Achilles tendon) tenotomy or orthotic devices (e.g., Denis Browne bar) may be used to maintain correction.

🔶 Early treatment is essential to prevent muscle shortening, joint stiffness, and deformity recurrence.

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Answer 9

Correct Answers:

weekly serial casting changes with manipulation."

Rationale :

💠 The first step in treating bilateral clubfoot is weekly serial casting with gentle manipulation of the foot to gradually align bones, ligaments, and tendons into a normal position.

💠 This approach, known as the Ponseti method, typically begins shortly after birth and involves changing the casts every 5–7 days as correction progresses.

💠 Once alignment is achieved, the correction is maintained using a Denis Browne bar or orthotic braces, not as the initial treatment.

💠 Surgical intervention (e.g., heel cord tenotomy) may be required later if full correction cannot be achieved through casting alone.

💠 The goal is to correct deformity early to ensure normal foot function and prevent long-term disability.

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Answer 10

Correct Answers:

Strawberry appearance of tongue

Rationale :

🔴 Kawasaki disease is an acute, systemic vasculitis that primarily affects children under 5 years of age and can lead to coronary artery aneurysms if untreated.

🔴 A “strawberry tongue” — bright red with prominent papillae — is a classic mucocutaneous manifestation of the disease, along with cracked lips and erythematous oral mucosa.

🔴 Other hallmark signs include high persistent fever, bilateral non-exudative conjunctivitis, rash on the trunk and extremities, edema or peeling of hands and feet, and cervical lymphadenopathy.

🔴 Early recognition and treatment with IV immunoglobulin (IVIG) and high-dose aspirin are critical to reduce the risk of cardiac complications.

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NSG 234 Exam II

No.

1 :
A nurse is developing a teaching plan for nutrition, for parents of a 4-year-old child diagnosed with cerebral palsy. Which of the following statements made by the parent demonstrate a good understanding of the teaching? SELECT ALL THAT APPLY "I will:

2 :
A nurse anticipates an order for which medication when a child is diagnosed with Kawasaki disease?

3 :
A nurse recognizes which of the following physical assessment findings of a one-year-old child may indicate a diagnosis of cerebral palsy?

4 :
A hospitalized 4-month old is diagnosed with diaper dermatitis. Which of the following actions would the nurse emphasize to the parent(s) related to preventative care? SELECT ALL THAT APPLY:

👶 B. Change diapers frequently

🧴 D. Remove soiled diapers promptly

🌿 E. Use non-irritant cleanser wipes

5 :
A nurse is caring for a 10-year-old child who has a surgically placed IIlizarov External Fixator (skeletal traction). Which of the following assessments by the nurse has the highest priority?

6 :
Which of the following is an appropriate nursing intervention when providing comfort and support for a child when death is imminent?

7 :
The nurse is caring for a child with a history of hemophilia A and a diagnosis of a right ankle hemarthrosis. The nurse would anticipate an order to administer:

8 :
The nurse is providing discharge teaching to parents of a newborn diagnosed with bilateral club foot. Which of the following statements made by the parents indicate an understanding of the instructions? "Our baby will first require:

9 :
The nurse is providing discharge teaching to parents of a newborn diagnosed with bilateral club foot. Which of the following statements made by the parents indicate an understanding of the instructions? "Our baby will first require:

10 :
A nurse is assessing a child admitted to the hospital with a diagnosis of Kawasaki Disease. The nurse performs an initial assessment. What clinical finding supports the diagnosis?

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NSG 234 Exam II

No.

1 : A nurse is developing a teaching plan for nutrition, for parents of a 4-year-old child diagnosed with cerebral palsy. Which of the following statements made by the parent demonstrate a good understanding of the teaching? SELECT ALL THAT APPLY "I will:

2 : A nurse anticipates an order for which medication when a child is diagnosed with Kawasaki disease?

3 : A nurse recognizes which of the following physical assessment findings of a one-year-old child may indicate a diagnosis of cerebral palsy?

4 : A hospitalized 4-month old is diagnosed with diaper dermatitis. Which of the following actions would the nurse emphasize to the parent(s) related to preventative care? SELECT ALL THAT APPLY:

👶 B. Change diapers frequently

🧴 D. Remove soiled diapers promptly

🌿 E. Use non-irritant cleanser wipes

5 : A nurse is caring for a 10-year-old child who has a surgically placed IIlizarov External Fixator (skeletal traction). Which of the following assessments by the nurse has the highest priority?

6 : Which of the following is an appropriate nursing intervention when providing comfort and support for a child when death is imminent?

7 : The nurse is caring for a child with a history of hemophilia A and a diagnosis of a right ankle hemarthrosis. The nurse would anticipate an order to administer:

8 : The nurse is providing discharge teaching to parents of a newborn diagnosed with bilateral club foot. Which of the following statements made by the parents indicate an understanding of the instructions? "Our baby will first require:

9 : The nurse is providing discharge teaching to parents of a newborn diagnosed with bilateral club foot. Which of the following statements made by the parents indicate an understanding of the instructions? "Our baby will first require:

10 : A nurse is assessing a child admitted to the hospital with a diagnosis of Kawasaki Disease. The nurse performs an initial assessment. What clinical finding supports the diagnosis?

1 :
A nurse is developing a teaching plan for nutrition, for parents of a 4-year-old child diagnosed with cerebral palsy. Which of the following statements made by the parent demonstrate a good understanding of the teaching? SELECT ALL THAT APPLY "I will:

2 :
A nurse anticipates an order for which medication when a child is diagnosed with Kawasaki disease?

3 :
A nurse recognizes which of the following physical assessment findings of a one-year-old child may indicate a diagnosis of cerebral palsy?

4 :
A hospitalized 4-month old is diagnosed with diaper dermatitis. Which of the following actions would the nurse emphasize to the parent(s) related to preventative care? SELECT ALL THAT APPLY:

5 :
A nurse is caring for a 10-year-old child who has a surgically placed IIlizarov External Fixator (skeletal traction). Which of the following assessments by the nurse has the highest priority?

6 :
Which of the following is an appropriate nursing intervention when providing comfort and support for a child when death is imminent?

7 :
The nurse is caring for a child with a history of hemophilia A and a diagnosis of a right ankle hemarthrosis. The nurse would anticipate an order to administer:

8 :
The nurse is providing discharge teaching to parents of a newborn diagnosed with bilateral club foot. Which of the following statements made by the parents indicate an understanding of the instructions? "Our baby will first require:

9 :
The nurse is providing discharge teaching to parents of a newborn diagnosed with bilateral club foot. Which of the following statements made by the parents indicate an understanding of the instructions? "Our baby will first require:

10 :
A nurse is assessing a child admitted to the hospital with a diagnosis of Kawasaki Disease. The nurse performs an initial assessment. What clinical finding supports the diagnosis?