When developing the plan of care for a child with cerebral palsy, which treatment would the nurse expect as least likely?

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Question 1 of 5

When developing the plan of care for a child with cerebral palsy, which treatment would the nurse expect as least likely?

Correct Answer: A

Rationale: In caring for a child with cerebral palsy, skeletal traction is least likely to be a part of the treatment plan. Cerebral palsy is a neurological disorder affecting movement and muscle coordination, and skeletal traction, which involves applying a pulling force on a bone to correct alignment, is not a common intervention for this condition. Physical therapy, orthotics, and occupational therapy are more commonly used in the management of cerebral palsy. Physical therapy helps improve mobility and strength, orthotics assist in supporting and aligning the body, and occupational therapy focuses on enhancing daily living skills and independence. Therefore, skeletal traction is the least likely treatment option among the choices provided.

Question 2 of 5

The caregiver is teaching the mother of a toddler about burn prevention. Which response by the mother indicates a need for further teaching?

Correct Answer: B

Rationale: Setting the water heater at 130 degrees can lead to scald burns. The recommended temperature setting for water heaters is no higher than 120 degrees to prevent burns. Choice A is correct as it shows awareness of the risks of fireworks. Choice C is correct as flame-retardant sleepwear can help prevent burns. Choice D is correct as inward-facing pot handles prevent accidental spills and burns. Option B is incorrect due to the unsafe water heater temperature setting.

Question 3 of 5

During a routine monthly examination, a 5-month-old infant is brought to the pediatric clinic. What assessment finding should alert the nurse to notify the health care provider immediately?

Correct Answer: D

Rationale: A respiratory rate of 50 breaths per minute in a 5-month-old infant is higher than the expected range and may indicate respiratory distress. This finding is concerning and should prompt the nurse to notify the health care provider for further evaluation and intervention. A temperature of 99.5°F, blood pressure of 75/48 mm Hg, and heart rate of 100 beats per minute are within normal ranges for a 5-month-old infant. Elevated temperature may indicate a mild fever, which can be monitored. A blood pressure of 75/48 mm Hg is within the normal range for infants. A heart rate of 100 beats per minute is also within the expected range for a 5-month-old infant and does not typically require immediate notification of the health care provider.

Question 4 of 5

What would a healthcare professional expect to find when assessing the skin of a child with cellulitis?

Correct Answer: B

Rationale: Cellulitis is characterized by warmth at the site of skin disruption, indicating an infection. The correct answer is choice B. Choice A, 'Red, raised hair follicles,' is more indicative of folliculitis rather than cellulitis. Choice C, 'Papules progressing to vesicles,' is more characteristic of conditions like chickenpox, not cellulitis. Choice D, 'Honey-colored exudate,' is typical of wound infections with bacteria like Staphylococcus aureus, not cellulitis.

Question 5 of 5

During a clinical conference with a group of nursing students, the instructor is describing burn classifications. The instructor determines that the teaching has been successful when the group identifies what as characteristic of full-thickness burns?

Correct Answer: D

Rationale: Full-thickness burns, also known as third-degree burns, are characterized by a leathery, dry appearance with numbness due to nerve damage. This type of burn extends through all layers of the skin, affecting nerve endings. Choice A describes characteristics of superficial partial-thickness burns, which involve the epidermis and part of the dermis. Choice B describes characteristics of superficial burns, or first-degree burns, which only affect the epidermis. Choice C describes characteristics of superficial to mid-dermal burns, also known as second-degree burns, which involve the epidermis and part of the dermis but do not extend through all skin layers. Therefore, the correct answer is D.

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