The nurse supervises a graduate nurse caring for a child with cerebral palsy. Which action by the graduate nurse requires intervention? The graduate nurse
The nurse supervises a graduate nurse caring for a child with cerebral palsy. Which action by the graduate nurse requires intervention? The graduate nurse
A. initiates gentle range-of-motion exercises for the client.
[8%]
B. lowers the bed to its lowest position.
[12%]
C. wheels the client to the playroom via a wheelchair.
[10%]
D. feeds the client with the head of the bed elevated at 30 degrees.
[69%]
Statistics
Subject/Lesson
Subject
Child Health
Lesson
Neurologic
Client Need
Test Plan
Reduction of Risk Potential
Related Topic
Potential for Alterations in Body Systems
Item Type
Item Type
Analysis
Explanation
Choice D is correct. Clients with cerebral palsy may have difficulty swallowing or controlling their oral secretions. Feeding the client with the head of the bed elevated at 30 degrees increases the risk of aspiration. The head of the bed should be elevated to at least 45 degrees to reduce the risk of aspiration during feeding.
Choice A is incorrect. Range of motion (ROM) exercises are performed to prevent contractures in this pediatric cerebral palsy client.
Choice B is incorrect. Lowering the bed to its lowest position is done to decrease the risk of injury in the event of a fall. Therefore, the nurse would be appropriate in lowering the bed to this position.
Choice C is incorrect. Transporting the client to the playroom allows the client to play. This action by the nurse represents an independent nursing action in which the nurse demonstrates client advocacy.
Learning Objective
When a newly licensed registered nurse (RN) is caring for a school-aged client with cerebral palsy, identify the RN feeding the client with the head of the bed elevated at 30 degrees as the action which would warrant intervention by the charge nurse.
Related Videos
2 Key Topics
Cerebral Palsy
31.9 Neurologic Disorders
Additional Info
✓ Aspiration pneumonitis and pneumonia are caused by inhaling toxic and/or irritant substances, most commonly large volumes of upper airway secretions or gastric contents, into the lungs
✓ Symptoms include cough and dyspnea
✓ Diagnosis is based on clinical presentation and chest x-ray findings
✓ Treatment and prognosis differ by aspirated substance
✓ The term "aspiration pneumonia" is used when the ability to protect the lower airway is compromised and/or a large volume is aspirated
