what are priority nursing interventions designed to do for a 4 year old child with cerebral palsy
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Medical Surgical Assignment Exam HESI

1. What are priority nursing interventions designed to do for a 4-year-old child with cerebral palsy?

Correct answer: C

Rationale: The correct answer is C: 'Assist the child to develop effective communication.' Children with cerebral palsy often face challenges with communication skills. Therefore, priority nursing interventions aim to help them improve their communication abilities. Choice A is incorrect because while education is important, the priority for a child with cerebral palsy is to address immediate needs. Choice B is incorrect as toileting, although important, is not the priority in this case. Choice D is incorrect as ambulation may not be feasible or the most critical concern for a child with cerebral palsy.

2. What is the hallmark sign of intussusception?

Correct answer: B

Rationale: The hallmark sign of intussusception is currant jelly-like stools, which result from the mixture of blood and mucus in the stool due to the sloughing of intestinal mucosa. Mucus-like stools (Choice A) are not typically associated with intussusception. Tarry, black stools (Choice C) are characteristic of gastrointestinal bleeding higher up in the gastrointestinal tract, such as from a peptic ulcer. Green, soft stools (Choice D) are more indicative of rapid transit through the intestines, possibly due to dietary factors or infections such as gastroenteritis.

3. A healthcare worker with no known exposure to tuberculosis has received a Mantoux tuberculosis skin test. The nurse's assessment of the test after 62 hours indicates 5mm of erythema without induration. Which is the best initial nursing action?

Correct answer: D

Rationale: A Mantoux tuberculosis skin test without induration is considered negative. In this case, with 5mm of erythema and no induration, the result is negative, indicating no current infection. The best initial nursing action is to document these negative results in the healthcare worker's medical record. Reviewing the history for possible exposure to TB is unnecessary as the test result is negative. Instructing the healthcare worker to return for a repeat test or referring for INH therapy is not warranted when the test is negative.

4. Which is a priority nursing intervention for the cognitively impaired child?

Correct answer: B

Rationale: The correct answer is B because nursing interventions for cognitively impaired children prioritize promoting loving interactions with family. This support helps in creating a nurturing environment that contributes to the child's well-being and development. Choice A is not the priority as good nutrition, though important, may not address the immediate emotional and social needs of the child. Choice C is vague and does not specify how stimulation will be provided. Choice D, contact with peers, is also valuable but not as crucial as the primary relationships and interactions within the family unit for a cognitively impaired child.

5. Laboratory findings indicate that a client’s serum potassium level is 2.5 mEq/L. What action should the nurse take?

Correct answer: C

Rationale: A serum potassium level of 2.5 mEq/L is critically low, indicating severe hypokalemia. In this situation, it is essential for the nurse to inform the healthcare provider promptly about the need for potassium replacement. Administering potassium supplements orally or increasing dietary potassium intake is not appropriate in cases of critically low potassium levels as immediate and precise replacement is necessary. Monitoring the client's ECG continuously is important in severe cases of hypokalemia, but the priority action should be to inform the healthcare provider for further management and treatment.

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