Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
Which statements made by the parent indicate that appropriate care is being provided to a 4-year-old who has spastic type cerebral palsy? (Select All that Apply.)
A. I perform range of motion exercises every 4 hours to help prevent contractures
I perform a range of motion exercises every 4 hours to help prevent contractures. This helps prevent the tightening of muscles and joints, reducing the risk of contractures common in spastic cerebral palsy.
B. I make sure that I use toys and activities that are appropriate for my child's chronological age
I make sure that I use toys and activities that are appropriate for my child's chronological age. While important, this does not specifically address the care needs related to spastic cerebral palsy.
C. I have utensils with large, padded handles to make it easier for my child to feed himself
I have utensils with large, padded handles to make it easier for my child to feed himself. Adaptive utensils promote independence in self-care activities.
D. I play games with my child every day to keep them as independent as possible
I play games with my child every day to keep them as independent as possible. Engaging in activities that promote independence and social interaction is beneficial for children with cerebral palsy.
E. I give my child carbidopa so that he will stop drooling
I give my child carbidopa so that he will stop drooling. Medications like carbidopa are not typically used to manage drooling associated with cerebral palsy and are not a primary care measure.
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Full Explanation
A. I perform a range of motion exercises every 4 hours to help prevent contractures. This helps prevent the tightening of muscles and joints, reducing the risk of contractures common in spastic cerebral palsy.
B. I make sure that I use toys and activities that are appropriate for my child's chronological age. While important, this does not specifically address the care needs related to spastic cerebral palsy.
C. I have utensils with large, padded handles to make it easier for my child to feed himself. Adaptive utensils promote independence in self-care activities.
D. I play games with my child every day to keep them as independent as possible. Engaging in activities that promote independence and social interaction is beneficial for children with cerebral palsy.
E. I give my child carbidopa so that he will stop drooling. Medications like carbidopa are not typically used to manage drooling associated with cerebral palsy and are not a primary care measure.
Similar Questions
A nurse in an outpatient setting is caring for a client.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Full Explanation
Potential Condition
Bulimia nervosa: The client has a BMI of 18.5, which is on the lower end of normal, indicating possible weight issues, but not the severe underweight typical of anorexia nervosa. The client describes cycles of binge eating followed by compensatory behaviors such as purging (using laxatives), which are characteristic of bulimia nervosa. The client expresses a preoccupation with food and body weight, and feelings of embarrassment about their eating habits, which align with bulimia nervosa.
Actions to Take
1. Assess binging and purging patterns: It's crucial to understand the frequency, triggers, and methods of binging and purging to tailor interventions effectively and to monitor the severity and progression of bulimia.
2. Encourage client to identify triggers for overeating: Identifying triggers for binging can help the client develop healthier coping mechanisms and reduce the occurrence of binge eating episodes.
Parameters to Monitor
1. Electrolyte levels: Frequent use of laxatives and purging behaviors can lead to electrolyte imbalances, which are potentially life-threatening and must be monitored regularly.
2. Frequency of compensatory behaviors: Tracking the frequency of purging behaviors (such as laxative use) helps assess the effectiveness of interventions and the client’s progress in reducing harmful behaviors.
Incorrect answers:
Actions to Take:
- Assess for and discourage provocative or seductive behaviour: This is more relevant to histrionic personality disorder, not bulimia nervosa.
- Weigh daily for the first week: While weighing the client can be part of the monitoring process, daily weigh-ins can increase anxiety and may not directly address the core issues of bulimia.
- Assess for consumption of right food items: While dietary intake is important, focusing solely on food items without addressing the psychological aspects may not be effective for treating bulimia.
Parameters to Monitor:
- Attention-seeking behaviours: More relevant to histrionic personality disorder than bulimia nervosa.
- Signs of infection: Not directly relevant unless there is evidence of a related health issue or a compromised immune system, which is not indicated in the provided information.
- Presence of lanugo: Lanugo is more commonly associated with anorexia nervosa due to severe malnutrition, not bulimia.
Identify a complication resulting from a cleft palate, the anatomical changes that lead to the complication, and the priority interventions for care.
Full Explanation
Complication: Otitis Media
Anatomical Changes:
- Small external ear structure: Infants born with a cleft palate often have smaller external ear structures, which can affect the drainage of fluids and increase the risk of infections.
- Horizontal eustachian tubes: Eustachian tubes in individuals with cleft palate are typically more horizontal than normal, impairing the drainage of fluid from the middle ear.
- Large tongue: A large tongue may obstruct the upper airway and interfere with normal swallowing and speaking functions.
Complication: Otitis Media
- Due to the anatomical changes associated with cleft palate, such as horizontal eustachian tubes and impaired drainage, individuals are prone to recurrent middle ear infections (otitis media). These infections can lead to fluid accumulation behind the eardrum, which can further impair hearing and potentially lead to more serious complications if untreated.
Priority Interventions:
- Ear drops (for otitis media): Ear drops containing antibiotics may be prescribed to treat bacterial infections in the middle ear, which are common in individuals with cleft palate.
- Rationale: Ear drops help to directly treat the infection in the ear canal and middle ear, reducing inflammation and preventing complications such as hearing loss or spread of infection.
- Corticosteroids (for inflammation): Corticosteroids may be used to reduce inflammation in the ear canal and middle ear, particularly in cases of severe otitis media.
- Rationale: Corticosteroids help to decrease swelling and inflammation, which can improve symptoms and aid in the healing process of the ear.
Identify the trimester when each fetal development finding occurs. Note: Each category must have at least 1 response option selected.
A. Gender can be determined
B. Surfactant production
C. Sucking occurs
D. Fetus has a heartbeat
E. Fetal respiratory movements begin
F. Increase in body fat
Full Explanation
1st Trimester (Conception-13 weeks)
- Fetus has a heartbeat: The fetal heartbeat can typically be detected around 6 weeks gestation using ultrasound, marking the beginning of cardiac development in the first trimester.
2nd Trimester (14-26 weeks)
- Gender can be determined: Gender determination through ultrasound is generally possible around the 18-20 week mark in the second trimester when fetal genitalia are more distinguishable.
3rd Trimester (27-40 weeks)
- Surfactant production: Surfactant production by the fetal lungs begins in the third trimester, usually around 24-28 weeks, but continues to increase throughout the remainder of pregnancy.
- Sucking occurs: Fetal sucking movements start to develop around the 28th week and become more coordinated as the third trimester progresses.
- Fetal respiratory movements begin: Fetal respiratory movements, where the fetus practices breathing by moving the diaphragm, begin in the third trimester to prepare for life outside the womb.
- Increase in body fat: The fetus begins to accumulate more body fat in the third trimester, which helps with thermoregulation and provides energy reserves for birth and early postnatal life.
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Finding |
1st Trimester Conception-13 weeks
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2nd Trimester 14-26 weeks
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3rd Trimester 27-40 weeks
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Gender can be determined |
☐ |
☒ |
☐ |
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Surfactant production |
☐ |
☐ |
☒ |
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Sucking occurs |
☐ |
☐ |
☒ |
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Fetus has a heartbeat |
☒ |
☐ |
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Fetal respiratory movements begin |
☐ |
☐ |
☒ |
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Increase in body fat |
☐ |
☐ |
☐ |