NURS 334 ACTUAL UPDATED Exam
Questions and CORRECT Answers
Kevin, age 4, has a history of premature delivery with cerebral palsy being diagnosed shortly
after birth. Assessment findings include quadriplegia and deficient verbal communication skills
but apparently normal level of intelligence. Kevin has been hospitalized several times in the past
because of respiratory infections and gastric reflux. During Kevin's regular follow-up visit, his
mother tells the nurse it is becoming harder to care for Kevin because of his needs. because of
Kevin's recent admission to the hospital for pneumonia, she worries that she is not giving Kevin
the care he needs.
1. The nurse should explain to Kevin's mother that one of the complications associated with
cerebral palsy is respiratory problems. Which of the following assessment findings could most
help explain why Kevin is having these problems?
a. Constant drooling, which contributes to wet clothing and chilling
b. Dietary imbalance with - CORRECT ANSWER -d
Kevin, age 4, has a history of premature delivery with cerebral palsy being diagnosed shortly
after birth. Assessment findings include quadriplegia and deficient verbal communication skills
but apparently normal level of intelligence. Kevin has been hospitalized several times in the past
because of respiratory infections and gastric reflux. During Kevin's regular follow-up visit, his
mother tells the nurse it is becoming harder to care for Kevin because of his needs. because of
Kevin's recent admission to the hospital for pneumonia, she worries that she is not giving Kevin
the care he needs.
2. Kevin's mother asks the nurse how she can improve Kevin's communication skills, and a
diagnosis of 'impaired verbal communication' is developed. Which of the following plans would
be most appropriate for Kevin at this time to improve his communication skills?
a. Purchase an electric typewriter or computer to facilitate commu - CORRECT ANSWER -b
Kevin, age 4, has a history of premature delivery with cerebral palsy being diagnosed shortly
after birth. Assessment findings include quadriplegia and deficient verbal communication skills
,but apparently normal level of intelligence. Kevin has been hospitalized several times in the past
because of respiratory infections and gastric reflux. During Kevin's regular follow-up visit, his
mother tells the nurse it is becoming harder to care for Kevin because of his needs. because of
Kevin's recent admission to the hospital for pneumonia, she worries that she is not giving Kevin
the care he needs.
3. The nurse recognizes that an additional diagnosis is altered family processes related to a client
with a lifelong disability. Which of the following implementations should the nurse recognize as
being important to include in the plan of care?
a. Explore potential for additional caregiving support
b. Refer the family to a sup - CORRECT ANSWER - d.
Identify 2 early warning signs/symptoms that can be associated with CP for each of the
following ages: (these have been answered for you.....spend a few minutes looking at the
differences)
Neonate
3 month old
6 month old
12 month old - CORRECT ANSWER - Neonate
Weak or absent sucking or swallowing difficulties Periods of apnea or bradycardia
Encephalopathic cry (high pitched) Extreme fussiness and irritability
Poor muscle tone Twitching of an arm or leg
Not moving extremities normally Absent or weak primitive reflex responses
3 month old
Feeding difficulties; may be caused by tongue thrust or poor swallowing
Irritability or listlessness Hypotonia
One/both hands in fisted position Strabismus
Presence of primitive reflexes brisk tendon reflex response
, 6 month old
Delay in reaching dev. Milestones Continued primitive reflexes
Hands remain clenched Hypertonia
Arching or tendency to stand when held up Lack of interest in people/toys
Unaware of or indifferent to environment. Stimuli Little if any spontaneous actions
12 month old
Inability to sit alone **Scissoring of lower extremities
Toe walking Abnormal crawl (if present)
Athetoid (irregular, twisting) movementPoor articulation or lack of speech
Identify appropriate nursing goals that would assist this family? - CORRECT ANSWER -
Help patient to achieve optimal physical mobility
Decrease risk for injury related to mobility limitations and neuromuscular impairmentDecrease
pain (chronic) related to involuntary muscle movements (spasticity) and treatments for muscle
spasticity
1. Kevin's mother tells the nurse that she knew something was wrong with him at a very early
age. Identify at least six warning signs associated with CP that Kevin's mother might have
observed. - CORRECT ANSWER - Increased muscle tone
Increased deep tendon reflexes and clonus (sudden dorsiflexion of the ankle or rapid distal
movement of the patella resulting in alternating spasm and relaxation of the muscles being
stretched)
Flexor, adductor, and internal rotator muscles more involved than extensor, abductor, and
external rotator muscles
Difficulty with fine and gross motor skills
Most common contracture is that of the heel cord
Hip adductor contractures leading to progressive subluxation and dislocation
Knee contractures
Scoliosis common
Questions and CORRECT Answers
Kevin, age 4, has a history of premature delivery with cerebral palsy being diagnosed shortly
after birth. Assessment findings include quadriplegia and deficient verbal communication skills
but apparently normal level of intelligence. Kevin has been hospitalized several times in the past
because of respiratory infections and gastric reflux. During Kevin's regular follow-up visit, his
mother tells the nurse it is becoming harder to care for Kevin because of his needs. because of
Kevin's recent admission to the hospital for pneumonia, she worries that she is not giving Kevin
the care he needs.
1. The nurse should explain to Kevin's mother that one of the complications associated with
cerebral palsy is respiratory problems. Which of the following assessment findings could most
help explain why Kevin is having these problems?
a. Constant drooling, which contributes to wet clothing and chilling
b. Dietary imbalance with - CORRECT ANSWER -d
Kevin, age 4, has a history of premature delivery with cerebral palsy being diagnosed shortly
after birth. Assessment findings include quadriplegia and deficient verbal communication skills
but apparently normal level of intelligence. Kevin has been hospitalized several times in the past
because of respiratory infections and gastric reflux. During Kevin's regular follow-up visit, his
mother tells the nurse it is becoming harder to care for Kevin because of his needs. because of
Kevin's recent admission to the hospital for pneumonia, she worries that she is not giving Kevin
the care he needs.
2. Kevin's mother asks the nurse how she can improve Kevin's communication skills, and a
diagnosis of 'impaired verbal communication' is developed. Which of the following plans would
be most appropriate for Kevin at this time to improve his communication skills?
a. Purchase an electric typewriter or computer to facilitate commu - CORRECT ANSWER -b
Kevin, age 4, has a history of premature delivery with cerebral palsy being diagnosed shortly
after birth. Assessment findings include quadriplegia and deficient verbal communication skills
,but apparently normal level of intelligence. Kevin has been hospitalized several times in the past
because of respiratory infections and gastric reflux. During Kevin's regular follow-up visit, his
mother tells the nurse it is becoming harder to care for Kevin because of his needs. because of
Kevin's recent admission to the hospital for pneumonia, she worries that she is not giving Kevin
the care he needs.
3. The nurse recognizes that an additional diagnosis is altered family processes related to a client
with a lifelong disability. Which of the following implementations should the nurse recognize as
being important to include in the plan of care?
a. Explore potential for additional caregiving support
b. Refer the family to a sup - CORRECT ANSWER - d.
Identify 2 early warning signs/symptoms that can be associated with CP for each of the
following ages: (these have been answered for you.....spend a few minutes looking at the
differences)
Neonate
3 month old
6 month old
12 month old - CORRECT ANSWER - Neonate
Weak or absent sucking or swallowing difficulties Periods of apnea or bradycardia
Encephalopathic cry (high pitched) Extreme fussiness and irritability
Poor muscle tone Twitching of an arm or leg
Not moving extremities normally Absent or weak primitive reflex responses
3 month old
Feeding difficulties; may be caused by tongue thrust or poor swallowing
Irritability or listlessness Hypotonia
One/both hands in fisted position Strabismus
Presence of primitive reflexes brisk tendon reflex response
, 6 month old
Delay in reaching dev. Milestones Continued primitive reflexes
Hands remain clenched Hypertonia
Arching or tendency to stand when held up Lack of interest in people/toys
Unaware of or indifferent to environment. Stimuli Little if any spontaneous actions
12 month old
Inability to sit alone **Scissoring of lower extremities
Toe walking Abnormal crawl (if present)
Athetoid (irregular, twisting) movementPoor articulation or lack of speech
Identify appropriate nursing goals that would assist this family? - CORRECT ANSWER -
Help patient to achieve optimal physical mobility
Decrease risk for injury related to mobility limitations and neuromuscular impairmentDecrease
pain (chronic) related to involuntary muscle movements (spasticity) and treatments for muscle
spasticity
1. Kevin's mother tells the nurse that she knew something was wrong with him at a very early
age. Identify at least six warning signs associated with CP that Kevin's mother might have
observed. - CORRECT ANSWER - Increased muscle tone
Increased deep tendon reflexes and clonus (sudden dorsiflexion of the ankle or rapid distal
movement of the patella resulting in alternating spasm and relaxation of the muscles being
stretched)
Flexor, adductor, and internal rotator muscles more involved than extensor, abductor, and
external rotator muscles
Difficulty with fine and gross motor skills
Most common contracture is that of the heel cord
Hip adductor contractures leading to progressive subluxation and dislocation
Knee contractures
Scoliosis common
