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. A child with a diagnosis of nephrotic syndrome is being discharged. What dietary instructions should the nurse provide?

Correct answer: B

Rationale: For a child with nephrotic syndrome, it is important to avoid foods high in salt. This instruction helps manage symptoms and prevent complications associated with the condition. High salt intake can lead to fluid retention and worsen edema, which are common issues in nephrotic syndrome. Encouraging a low-sodium diet is crucial to maintaining fluid balance and reducing strain on the kidneys. Choices A, C, and D are incorrect because a high-protein diet can further stress the kidneys, while a low-protein diet may not be necessary unless specifically advised by the healthcare provider. Encouraging a low-sodium diet is more appropriate for managing nephrotic syndrome.

3. While assessing an 18-month-old child, a nurse observes that the toddler can crawl upstairs but needs assistance when climbing the stairs upright. What does this action indicate to the nurse?

Correct answer: C

Rationale: At 18 months of age, needing assistance to climb stairs upright is considered normal behavior for a toddler. Crawling upstairs is a different motor skill and does not necessarily correlate with the ability to climb stairs. The child is still developing gross motor skills, and climbing stairs upright typically requires more coordination and strength, which may not be fully developed at this age. Choices A, B, and D are not relevant in this scenario as the observed behavior is within the expected range of development for an 18-month-old child.

4. What should be included in the preoperative teaching for a 4-year-old child scheduled for a tonsillectomy?

Correct answer: B

Rationale: Encouraging deep breathing exercises is important preoperative teaching for a child scheduled for a tonsillectomy. Deep breathing exercises can help the child relax and reduce anxiety, which is beneficial before the procedure. Explaining the procedure in detail might be overwhelming for a 4-year-old, whereas encouraging deep breathing exercises can be more beneficial in promoting relaxation and preparing the child. Discussing the importance of hydration is crucial for postoperative care but may not be the priority for preoperative teaching. Using play therapy can help prepare the child, but encouraging deep breathing exercises is more directly related to relaxation and preparation for the procedure.

5. A child with a diagnosis of pyloric stenosis is scheduled for surgery. What preoperative intervention is important for the nurse to perform?

Correct answer: C

Rationale: The correct preoperative intervention for a child with pyloric stenosis is to monitor for signs of dehydration. Pyloric stenosis can lead to vomiting, which can result in dehydration. Monitoring for signs of dehydration is crucial to ensure the child's fluid balance is maintained. Administering intravenous fluids, although important for managing dehydration and electrolyte imbalances, would typically be done postoperatively rather than as a preoperative intervention. Monitoring for signs of infection is important but not specific to the preoperative period for pyloric stenosis. Monitoring for signs of pain is also important but may not be the most critical preoperative intervention in this scenario.

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