Dif cognitive level applying ref p 1622 top

DIF: Cognitive Level: Applying REF: p. 1622
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
8.
A child, age 3 years, has cerebral palsy (CP) and is hospitalized for orthopedic surgery. His
mother says he has difficulty swallowing and cannot hold a utensil to feed himself. He is
slightly underweight for his height. What is the most appropriate nursing action related to
feeding this child?
a. Bottle or tube feed him a specialized formula until he gains sufficient weight.
b. Stabilize his jaw with caregiver’s hand (either from a front or side position) to
facilitate swallowing.
c. Place him in a well-supported, semireclining position.
d. Place him in a sitting position with his neck hyperextended to make use of gravity
flow.
ANS: B
Jaw control is compromised in many children with CP. More normal control is achieved if the
feeder stabilizes the oral mechanisms from the front or side of the face. Bottle or tube feeding
will not improve feeding without jaw support. The semireclining position and hyperextended
neck position increase the chances of aspiration.
DIF: Cognitive Level: Applying REF: p. 1625
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
9.
An 8-year-old girl with moderate cerebral palsy (CP) recently began joining a regular
classroom for part of the day. Her mother asks the school nurse about joining the after-school
Girl Scout troop. The nurse’s response should be based on which knowledge?

DIF: Cognitive Level: Applying REF: p. 1626
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Psychosocial Integrity