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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Nursing Elites

HESI LPN

Pediatric Practice Exam HESI

1. 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.

2. What are general guidelines when assessing a 2-year-old child with abdominal pain and adequate perfusion?

Correct answer: A

Rationale: When assessing a 2-year-old child with abdominal pain and adequate perfusion, it is important to examine the child in the parent's arms. This approach helps reduce the child's anxiety, provides comfort, and can facilitate a more accurate assessment. Palpating the painful area of the abdomen first (choice B) may cause discomfort and increase anxiety in the child. Placing the child supine and palpating the abdomen (choice C) without considering the child's comfort and security may lead to resistance and inaccurate assessment. Separating the child from the parent to ensure a reliable examination (choice D) can further increase anxiety and hinder the assessment process. Therefore, examining the child in the parent's arms (choice A) is the most appropriate and effective approach in this scenario.

3. A nurse is teaching a parent how to prevent accidents while caring for a 6-month-old infant. What ability should be emphasized regarding the infant’s motor development?

Correct answer: B

Rationale: The correct answer is "B: Rolls over." At 6 months, most infants can roll over, which increases the risk of falls. Emphasizing the infant's ability to roll over is crucial to highlight the need for careful supervision and accident prevention. Choices A, C, and D are incorrect because sitting up, crawling short distances, and standing while holding on to furniture typically develop later in an infant's motor skills progression and are not as directly associated with an increased risk of accidents at this stage.

4. In an adolescent suspected of having type 1 diabetes mellitus, which clinical manifestation may be present?

Correct answer: D

Rationale: Poor wound healing is a common clinical manifestation of type 1 diabetes mellitus. Elevated blood glucose levels in diabetes can lead to impaired wound healing by affecting various cellular processes involved in the healing cascade. Moist skin (Choice A) is not typically associated with type 1 diabetes mellitus. Weight gain (Choice B) is more commonly seen in type 2 diabetes due to insulin resistance. Fluid overload (Choice C) is not a typical clinical manifestation of type 1 diabetes mellitus. Therefore, the correct answer is poor wound healing.

5. An infant who had cardiac surgery for a congenital defect is to be discharged. What should the nurse emphasize to the parents regarding administering the prescribed antibiotic?

Correct answer: B

Rationale: The correct answer is B: 'Ensure that the antibiotic is administered as prescribed.' It's crucial to stress the importance of following the prescribed antibiotic regimen to prevent infections and promote proper healing after cardiac surgery. Choice A is incorrect because it does not address the fundamental aspect of adherence to the prescription. Choice C is incorrect as shaking the bottle may not be necessary for all antibiotics and is not a critical instruction in this context. Choice D is incorrect as storage instructions are not directly related to the administration of the antibiotic as prescribed, which is the primary concern in this scenario.

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