Author Question: The nurse is caring for a 2-month-old with cerebral palsy. The infant is limp and flaccid with ... (Read 64 times)

karen · **on:** Jun 27, 2018

The nurse is caring for a 2-month-old with cerebral palsy. The infant is limp and flaccid with uncontrolled, slow, worm-like, writhing, and twisting movements. Which of the following would the nurse use when documenting these observations?

A) Spastic
B) Athetoid
C) Ataxic
D) Mixed

Question 2

The nurse has developed a plan of care for a 6-year-old with muscular dystrophy. He was recently injured when he fell out of bed at home. Which intervention would the nurse suggest to prevent further injury?

A) Recommend the bed's side rails be raised throughout the day and night.
B) Suggest a caregiver be present continuously to prevent falls from bed.
C) Encourage a loose restraint to be used when he is in bed.
D) Recommend raising the bed's side rails when a caregiver is not present.

Swizqar · **Reply #1 on:** Jun 27, 2018

Answer to Question 1

B
Feedback:
Athetoid cerebral palsy is characterized by abnormal, involuntary movement. It affects all four extremities with possible involvement of the face, neck, and tongue. The movements increase in periods of stress. Dysarthria and drooling may be present as well. Spastic cerebral palsy is characterized by poor control of posture, balance, and movement; exaggeration of deep tendon reflexes; and hypertonicity of affected extremities. Ataxic is characterized by poor coordination, unsteady gait, and wide-based gait.

Answer to Question 2

D
Feedback:
The nurse should recommend that side rails on the bed be elevated when a caregiver is not present. The use of restraints should be avoided if at all possible. Suggesting that a caregiver be present at all times places undue stress on the family. Close observation is more appropriate. Recommending side rails be elevated at all times may be upsetting to the child and make him feel like a baby..