The nurse is caring for an 8-year-old child with developmental ...

[imowrer]

The nurse is caring for an 8-year-old child with developmental delays who is unable to tie his shoes. The nurse will plan care to help this child normalize, and will develop which of the following goals?
 
  1. Child will tie his shoes within one week.
  2. Child will attempt to tie his shoes each morning when dressing.
  3. Child will tie his shoes after process is demonstrated.
  4. Child will wear shoes without laces.

Question 2

The nurse is bathing a client who suddenly begins to display tonic-clonic muscle activity. The client does not have a history of seizures. After providing for the client's safety, what is the nurse's priority of care?
 
  1. Assess vital signs.
  2. Time the seizure.
  3. Complete the bath.
  4. Cover the client with a blanket.

[tashiedavis420]

Answer to Question 1

2
Rationale: Expectations for the child must be reasonable. The child might or might not learn to tie his shoes, and the time it takes to learn will vary with individual children. However, it is possible for the child to attempt to tie his shoes, and this would be expecting behavior that is possible.

Answer to Question 2

2
Rationale: The nurse's priority is to time the seizure, because the provider will want to know how long it lasted and what occurred during the seizure. The nurse will carefully document what was observed, the length of time the seizure continued, and the client's condition after the seizure subsided. It is not safe to restrain the client to obtain vital signs during the seizure, and placement of a blanket would be futile because it would be kicked off by the clonic tonic movements. The nurse will not complete the bath but will change the plan of care based on the change in the client's status.

[imowrer]

TYSM

[coreycathey]

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