Question

A home health nurse is doing the first intake visit for a child who has hemiplegic cerebral palsy. When developing a plan of care for this child, which of the following goals is the priority for the nurse to include in the plan of care?

Answer 1

Correct Answers:

Modify the home for safety

Rationale :

🔒Safety is the top priority when caring for a child with hemiplegic cerebral palsy, as these children have limited mobility on one side and are at high risk for falls and injuries in an unsafe environment.

🛋️Environmental modifications such as removing rugs, installing grab bars, and ensuring clear pathways reduce the risk of accidents and support independence.

🚸Although promoting independence in ADLs is important, it comes after ensuring the child's physical safety in the home.

🧭Planning for respite care and improving communication are valuable, but these goals do not supersede the immediate need for a secure and supportive environment.

📌Core Message

Ensuring home safety is the immediate and most critical priority when planning care for a child with hemiplegic cerebral palsy, as it prevents injury and supports overall function.

Answer 2

Correct Answers:

Apply direct pressure at the site and one inch above the catheterization site

Rationale :

🩹Bleeding after a cardiac catheterization requires immediate hemostatic action, and applying direct pressure is the fastest and most effective way to stop the bleeding.

📍Applying pressure one inch above helps compress the artery and control bleeding if it's arterial in nature.

📞While notifying the provider is necessary, it is not the first action—delayed bleeding control could lead to hemorrhage or shock.

🛏️Trendelenburg positioning and reinforcing the dressing do not address the source of bleeding directly and are not effective as initial emergency measures.

📌Core Message

Applying direct pressure is the first and most urgent intervention when active bleeding is observed post-catheterization to prevent rapid blood loss and stabilize the child.

Answer 3

Correct Answers:

Immediately report this finding as this is life threatening

Rationale :

🧯A sudden cessation of chest tube drainage after open heart surgery may indicate a life-threatening complication such as cardiac tamponade or tube obstruction.

📞This is considered a surgical emergency, and prompt reporting to the healthcare provider is essential to prevent deterioration.

📉Waiting or encouraging breathing exercises may cause a delay in care, potentially leading to cardiac arrest or death.

📋While documentation is important, the nurse must first act to prevent a critical event, especially in the presence of a potentially obstructed drainage system.

📌Core Message

Absent chest tube drainage after cardiac surgery should be treated as an emergency, warranting immediate reporting due to risk of tamponade or tube obstruction.

Answer 4

Correct Answers:

"Would you like to talk about your decision and discuss alternatives?"

Rationale :

🧠Children with cerebral palsy benefit from inclusion and socialization, and open communication helps parents explore adapted opportunities.

🫂This response demonstrates empathy, nonjudgmental support, and helps foster a collaborative approach to problem-solving.

⚖️By offering to discuss alternatives, the nurse respects the parents' decision while also encouraging them to consider adapted options that maintain the child’s interests.

🎭Other responses are either dismissive or finalizing, and they fail to promote inclusion or empowerment for the child and family.

📌Core Message

Open-ended, supportive communication fosters inclusion and helps families explore adapted activities for children with cerebral palsy while maintaining autonomy.

Answer 5

Correct Answers:

Treatment for strep throat within the last two weeks

Rationale :

🧫Acute post-streptococcal glomerulonephritis (APSGN) is a known complication that can develop 1–2 weeks after a strep throat infection.

🔬The condition results from immune complex deposition in the glomeruli, causing inflammation and impaired kidney function.

🧪Symptoms include hematuria, proteinuria, hypertension, and edema, which may occur after seemingly resolved upper respiratory infections.

🤧A history of allergic symptoms, viral illness, or UTI does not strongly correlate with APSGN like a recent Group A Streptococcus infection does.

📌Core Message

Recent streptococcal infection is the classic precursor for glomerulonephritis, due to immune-mediated damage to the glomeruli.

Answer 6

Correct Answers

Monitor RLE pulses with vital signs [ Anticipated ]
Administer Oxycodone 3 mg Q3-4 hours PRN for pain [ Anticipated ]
Continue IV NSS bolus @ 67 ml/hour [ Anticipated ]
Decrease 02 to 2 L/min [ Contraindicated ]

Rationale :

🦵Monitoring pulses in the affected limbs is essential in vaso-occlusive crisis to assess for potential circulatory compromise or ischemia.

💊Pain control using opioids like oxycodone is a cornerstone in treating vaso-occlusive episodes to reduce stress and oxygen demand.

💧Hydration with IV fluids helps reduce blood viscosity and promotes circulation, aiding in crisis resolution.

⛔Reducing oxygen is contraindicated during a crisis when hypoxia may precipitate or worsen sickling; oxygen should be maintained or titrated based on saturation.

📌Core Message

Management of vaso-occlusive crisis involves supporting perfusion, oxygenation, and pain control, while avoiding interventions that may worsen hypoxia.

Answer 7

Correct Answers:

Lumbar puncture

Rationale :

🔍A lumbar puncture can assess for central nervous system involvement, which is critical in staging neuroblastoma and determining metastasis.

🧬Neuroblastoma often metastasizes to the bone marrow and CNS, and CSF analysis provides important diagnostic information.

📊A basic metabolic panel is unrelated to tumor staging—it evaluates electrolyte and renal function.

🧪While a biopsy confirms the diagnosis, it doesn’t evaluate spread, and a head CT only checks intracranial structures.

📌Core Message

Lumbar puncture helps assess metastasis in neuroblastoma, particularly for CNS involvement, which influences staging and treatment.

Answer 8

Correct Answers:

An apical pulse of 70 beats/minute and vomiting

Rationale :

🧠Digoxin toxicity presents with signs such as bradycardia and vomiting, both of which are evident in this scenario and are highly concerning.

🩺In a child, an apical pulse of 70 bpm is too low and may indicate dangerous digoxin accumulation, warranting immediate assessment.

🤢Vomiting is often one of the earliest signs of toxicity, especially in pediatric patients who may not communicate discomfort clearly.

⚠️Other options may show mild or expected findings, but this combination is a red flag for potentially life-threatening cardiac arrhythmia.

📌Core Message

Bradycardia with vomiting in a child on digoxin strongly suggests toxicity, requiring urgent evaluation and intervention.

Answer 9

Correct Answers:

Prone with hips flexed and legs abducted

Rationale :

🍼Infants with myelomeningocele should be placed prone with hips flexed and legs abducted to avoid pressure on the sac and reduce the risk of rupture or infection.

🧼This positioning also facilitates cleanliness and keeps the exposed spinal cord safe before surgical repair.

🔄Supine or Trendelenburg positions would place direct pressure on the defect, potentially causing neuro damage or CSF leakage.

🧸The side-lying position is also unsafe as it provides less protection and stability for the sac.

📌Core Message

Prone positioning with hip flexion and leg abduction protects the myelomeningocele sac and prevents neurological and infectious complications preoperatively.

Answer 10

Correct Answers:

1400: Basketball practice, dizzy no loss of consciousness, no caffeine today.

Rationale :

🕓Holter monitor diaries are used to correlate symptoms and activities with cardiac rhythm changes, so the entry must include time, activity, symptoms, and relevant contributing factors.

⚽This option clearly documents the time (1400), activity (basketball), symptoms (dizziness), and no loss of consciousness, as well as a relevant factor (no caffeine).

📉This level of detail allows clinicians to interpret rhythm irregularities in relation to physical exertion or other triggers.

📝Other options either list only vital signs, locations of electrodes, or diet—none of which correlate with symptoms or meet complete documentation standards for Holter monitor evaluation.

📌Core Message

The most complete Holter diary entry is one that includes time, activity, symptoms, and relevant factors, which supports accurate correlation with rhythm data.

Options	Anticipated	Contraindicated
Monitor RLE pulses with vital signs
Administer Oxycodone 3 mg Q3-4 hours PRN for pain
Continue IV NSS bolus @ 67 ml/hour
Decrease 02 to 2 L/min

1 :
A home health nurse is doing the first intake visit for a child who has hemiplegic cerebral palsy. When developing a plan of care for this child, which of the following goals is the priority for the nurse to include in the plan of care?

2 :
The nurse is caring for a school-age girl who had an arterial cardiac catheterization. The child tells the nurse that the bandage is "wet." On assessment, the bandage and bed are soaked with blood. The nurse must do which of the following FIRST?

3 :
The nurse is caring for a preschool aged child immediately following an open repair of a Ventricular Septal Defect. There has been no drainage from the mediastinal chest tubes in the last 2 hours. Based on this finding what will be the nurse's priority intervention?

4 :
A nurse is speaking with the parents of a 4-year-old boy who has a cerebral palsy. The parents tell the nurse they have taken their son's name off the list for baseball next season. Which of the following is the BEST response for the nurse to make?

5 :
A school aged child is being evaluated for possible glomerulonephritis. During the physical exam the nurse recognizes that which of the following, is a possible cause?

6 :
The nurse is admitting a 6-year-old child with Sickle Cell Anemia who is being admitted for vaso-occlusive crisis.

Correct Answers

7 :
A 2-year-old child is diagnosed with neuroblastoma. The nurse understands that which of the following tests help to determine the extent of tumor metastasis?

8 :
A 3-year-old child with congestive heart failure resulting from an underlying congenital heart defect, is prescribed digoxin and furosemide. Which of the following assessment findings are MOST concerning?

9 :
The nurse understands that in the preoperative period the infant with a myelomeningocele must be placed in which of the following positions?

10 :
The nurse is reviewing 24-hour Holter monitor diaries of various patients. Which of the following entries is the MOST complete?

1 : A home health nurse is doing the first intake visit for a child who has hemiplegic cerebral palsy. When developing a plan of care for this child, which of the following goals is the priority for the nurse to include in the plan of care?

2 : The nurse is caring for a school-age girl who had an arterial cardiac catheterization. The child tells the nurse that the bandage is "wet." On assessment, the bandage and bed are soaked with blood. The nurse must do which of the following FIRST?

3 : The nurse is caring for a preschool aged child immediately following an open repair of a Ventricular Septal Defect. There has been no drainage from the mediastinal chest tubes in the last 2 hours. Based on this finding what will be the nurse's priority intervention?

4 : A nurse is speaking with the parents of a 4-year-old boy who has a cerebral palsy. The parents tell the nurse they have taken their son's name off the list for baseball next season. Which of the following is the BEST response for the nurse to make?

5 : A school aged child is being evaluated for possible glomerulonephritis. During the physical exam the nurse recognizes that which of the following, is a possible cause?

6 : The nurse is admitting a 6-year-old child with Sickle Cell Anemia who is being admitted for vaso-occlusive crisis.

Correct Answers

7 : A 2-year-old child is diagnosed with neuroblastoma. The nurse understands that which of the following tests help to determine the extent of tumor metastasis?

8 : A 3-year-old child with congestive heart failure resulting from an underlying congenital heart defect, is prescribed digoxin and furosemide. Which of the following assessment findings are MOST concerning?

9 : The nurse understands that in the preoperative period the infant with a myelomeningocele must be placed in which of the following positions?

10 : The nurse is reviewing 24-hour Holter monitor diaries of various patients. Which of the following entries is the MOST complete?

1 :
A home health nurse is doing the first intake visit for a child who has hemiplegic cerebral palsy. When developing a plan of care for this child, which of the following goals is the priority for the nurse to include in the plan of care?

2 :
The nurse is caring for a school-age girl who had an arterial cardiac catheterization. The child tells the nurse that the bandage is "wet." On assessment, the bandage and bed are soaked with blood. The nurse must do which of the following FIRST?

3 :
The nurse is caring for a preschool aged child immediately following an open repair of a Ventricular Septal Defect. There has been no drainage from the mediastinal chest tubes in the last 2 hours. Based on this finding what will be the nurse's priority intervention?

4 :
A nurse is speaking with the parents of a 4-year-old boy who has a cerebral palsy. The parents tell the nurse they have taken their son's name off the list for baseball next season. Which of the following is the BEST response for the nurse to make?

5 :
A school aged child is being evaluated for possible glomerulonephritis. During the physical exam the nurse recognizes that which of the following, is a possible cause?

6 :
The nurse is admitting a 6-year-old child with Sickle Cell Anemia who is being admitted for vaso-occlusive crisis.

7 :
A 2-year-old child is diagnosed with neuroblastoma. The nurse understands that which of the following tests help to determine the extent of tumor metastasis?

8 :
A 3-year-old child with congestive heart failure resulting from an underlying congenital heart defect, is prescribed digoxin and furosemide. Which of the following assessment findings are MOST concerning?

9 :
The nurse understands that in the preoperative period the infant with a myelomeningocele must be placed in which of the following positions?

10 :
The nurse is reviewing 24-hour Holter monitor diaries of various patients. Which of the following entries is the MOST complete?