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NURS 355 Chapter 21
Terms in this set (50)
The American Association on Intellectual and Developmental Disabilities (AAIDD), formerly the American Association on Cognitive Impairment, classifies cognitive impairment based on what parameter?
Adaptive skill domains
The AAIDD has categorized cognitive impairment into adaptive skill domains. The child must demonstrate functional impairment in at least two of the following adaptive skill domains: communication, self-care, home living, social skills, use of community resources, self-direction, health and safety, functional academics, leisure, and work. Age of onset before 18 years is part of the former criteria. Low intelligence quotient (IQ) alone is not the sole criterion for cognitive impairment. Etiology is not part of the classification.
Secondary prevention for cognitive impairment includes what activity?
Newborn screening for treatable inborn errors of metabolism
Secondary prevention involves activities that are designed to identify the condition early and initiate treatment to avert cerebral damage. Inborn errors of metabolism such as hypothyroidism, phenylketonuria, and galactosemia can cause cognitive impairment. Genetic counseling and avoidance of prenatal rubella infections are examples of primary prevention strategies to preclude the occurrence of disorders that can cause cognitive impairment. Preschool education and counseling services are examples of tertiary prevention. These are designed to include early identification of conditions and provision of appropriate therapies and rehabilitation services.
What is a primary goal in caring for a child with cognitive impairment?
Promoting optimum development
The goal for children with cognitive impairment is the promotion of optimum social, physical, cognitive, and adaptive development as individuals within a family and community. Vocational skills are only one part of that goal. The focus must also be on the family and other aspects of development. Out-of-home care is considered part of the child's development. Optimum development includes adjustment for both the family and child.
One of the techniques that has been especially useful for learners having cognitive impairment is called fading. What description best explains this technique?
Gradually reduces the assistance given to the child so the child becomes more independent
Fading is physically taking the child through each sequence of the desired activity and gradually fading out the physical assistance so the child becomes more independent. Positive reinforcement when tasks or behaviors are mastered is part of behavior modification. An essential component is ignoring undesirable behaviors. Verbal explanations are not as effective as demonstration and physical guidance. Consistent negative reinforcement is helpful, but positive reinforcement that focuses on skill attainment should be incorporated.
The parents of a child with cognitive impairment ask the nurse for guidance with discipline. What should the nurse's recommendation be based on?
Behavior modification is an excellent form of discipline
Discipline must begin early. Limit-setting measures must be clear, simple, consistent, and appropriate for the child's mental age. Behavior modification, especially reinforcement of desired behavior and use of time-out procedures, is an appropriate form of behavior control. Aversive strategies should be avoided in disciplining the child.
What intervention is most appropriate to facilitate social development of a child with a cognitive impairment?
Provide peer experiences, such as infant stimulation and preschool programs.
The acquisition of social skills is a complex task. Initially, an infant stimulation program should be used. Children of all ages need peer relationships. Parents should enroll the child in preschool. When older, they should have peer experiences similar to those of other children such as group outings, Boy and Girl Scouts, and Special Olympics. Providing age-appropriate toys and play activities is important, but peer interactions facilitate social development. Parents should expose the child to individuals who do not know the child. This enables the child to practice social skills. Verbal skills are delayed more often than physical skills.
The nurse is discussing sexuality with the parents of an adolescent girl who has a moderate cognitive impairment. What factor should the nurse consider when dealing with this issue?
Individuals with cognitive impairment need a well-defined, concrete code of sexual conduct.
Adolescents with moderate cognitive impairment may be easily persuaded and lack judgment. A well-defined, concrete code of conduct with specific instructions for handling certain situations should be defined for the adolescent. Permanent contraception by sterilization presents moral and ethical issues and may have psychologic effects on the adolescent. It may be prohibited in some states. The adolescent needs to have practical sexual information regarding physical development and contraception. Cognitively impaired individuals may desire to marry and have families. The adolescent needs to be protected from individuals who may make intimate advances.
The mother of a young child with cognitive impairment asks for suggestions about how to teach her child to use a spoon for eating. The nurse should make which recommendation?
Do a task analysis first
Successful teaching begins with a task analysis. The endpoint (self-feeding, toilet training, and so on) is broken down into the component steps. The child is then guided to master the individual steps in sequence. Depending on the child's functional level, using a spoon for eating should be an achievable goal. The child requires demonstration and then guided training for each component of the self-feeding. Feeding finger foods so spoon feeding is unnecessary eliminates some of the intermediate steps that are necessary to using a fork and spoon. For socialization purposes, it is desirable that a child use feeding implements.
A newborn assessment shows a separated sagittal suture, oblique palpebral fissures, a depressed nasal bridge, a protruding tongue, and transverse palmar creases. These findings are most suggestive of which condition?
These are characteristics associated with Down syndrome. An infant with microcephaly has a small head. Cerebral palsy is a diagnosis not usually made at birth; no characteristic physical signs are present. The infant with fragile X syndrome has increased head circumference; long, wide, or protruding ears; a long, narrow face with a prominent jaw; hypotonia; and a high-arched palate.
A 2-week-old infant with Down syndrome is being seen in the clinic. His mother tells the nurse that he is difficult to hold, that "he's like a rag doll. He doesn't cuddle up to me like my other babies did." What is the nurse's best interpretation of this lack of clinging or molding?
A physical characteristic of Down syndrome
Infants with Down syndrome have hypotonicity of muscles and hyperextensibility of joints, which complicate positioning. The limp, flaccid extremities resemble the posture of a rag doll. Holding the infant is difficult and cumbersome, and parents may feel that they are inadequate. A lack of clinging or molding is characteristic of Down syndrome, not detachment. There is no evidence of maternal deprivation. Autism is not associated with Down syndrome, and it would not be evident at 2 weeks of age.
Many of the clinical features of Down syndrome present challenges to caregivers. Based on these features, what intervention should be included in the child's care?
Use a cool-mist vaporizer to keep the mucous membranes moist and secretions liquefied.
The constant stuffy nose forces the child to breathe by mouth, drying the mucous membranes and increasing the susceptibility to upper respiratory tract infections. A cool-mist vaporizer will keep the mucous membranes moist and liquefy secretions. Respiratory tract infections combined with cardiac anomalies are the primary cause of death in the first years. The child has a protruding tongue, which makes feeding difficult. The parents must persist with feeding while the child continues the physiologic response of the tongue thrust. The child is predisposed to constipation. Calories should be appropriate to the child's weight and growth needs, not mental age.
What description applies to fragile X syndrome?
Second most common genetic cause of cognitive impairment
Fragile X syndrome is the most common inherited cause of cognitive impairment and the second most common genetic cause of cognitive impairment after Down syndrome. Fragile X primarily affects males and follows the pattern of X-linked dominant inheritance with reduced penetrance.
The nurse should suspect a hearing impairment in an infant who fails to demonstrate which behavior?
Babbling by age 12 months
The absence of babbling or inflections in voice by at least age 7 months is an indication of hearing difficulties. Lack of eye contact is not indicative of a hearing loss. An infant with a hearing impairment might react to a loud noise but not respond to the spoken word. The child with hearing impairment uses gestures rather than vocalizations to express desires at this age.
The nurse is talking with a 10-year-old boy who wears bilateral hearing aids. The left hearing aid is making an annoying whistling sound that the child cannot hear. What intervention is the most appropriate nursing action?
Suggest he reinsert the hearing aid
The whistling sound is acoustic feedback. The nurse should have the child remove the hearing aid and reinsert it, making sure no hair is caught between the ear mold and the ear canal. Ignoring the sound or suggesting he raise the volume of the hearing aid would be annoying to others. The hearing aids are molded specifically for each ear.
What technique facilitates lip reading by a hearing-impaired child?
Speak at an even rate
Help the child learn and understand how to read lips by speaking at an even rate. Avoiding using facial expressions, exaggerating pronunciation of words, and repeating in exactly the same way if the child does not understand interfere with the child's understanding of the spoken word.
What condition is defined as reduced visual acuity in one eye despite appropriate optical correction?
Amblyopia, or lazy eye, is reduced visual acuity in one eye. Amblyopia is usually caused by one eye not receiving sufficient stimulation. The resulting poor vision in the affected eye can be avoided with the treatment of the primary visual defect such as strabismus. Myopia, or nearsightedness, refers to the ability to see objects clearly at close range but not a distance. Hyperopia, or farsightedness, is the ability to see objects at a distance but not at close range. Astigmatism is unequal curvatures in refractive apparatus.
The school nurse is caring for a child with a penetrating eye injury. Emergency treatment includes what intervention?
Apply a Fox shield to the affected eye and any type of patch to the other eye.
The nurse's role in a penetrating eye injury is to prevent further injury to the eye. A Fox shield (if available) should be applied to the injured eye and a regular eye patch to the other eye to prevent bilateral movement. Placing cool compress on the eye during transport to emergency department, irrigating eye copiously with a sterile saline solution, or removing object with a lightly moistened gauze pad may cause more damage to the eye.
A father calls the emergency department nurse saying that his daughter's eyes burn after getting some dishwasher detergent in them. The nurse recommends that the child be seen in the emergency department or by an ophthalmologist. The nurse also should recommend which action before the child is transported?
Irrigate the eyes copiously with tap water for 20 minutes.
The first action is to flush the eyes with clean tap water. This will rinse the detergent from the eyes. Keeping the eyes closed and applying cold compresses may allow the detergent to do further harm to the eyes during transport. Normal saline is not necessary. The delay can allow the detergent to cause continued injury to the eyes.
A 5-year-old child has bilateral eye patches in place after surgery yesterday morning. Today he can be out of bed. What nursing intervention is most important at this time?
Orient him to his immediate surroundings
Safety is the priority concern. Because he can now be out of bed, it is imperative that he knows about his physical surroundings. Speaking to the child is a component of nursing care that is expected with all clients unless contraindicated. Unless additional impairments are present, his meal tray should be set up, and he should be able to feed himself. Reassuring him and allowing his parents to stay with him are essential parts of nursing care for all children.
Autism is a complex developmental disorder. The diagnostic criteria for autism include delayed or abnormal functioning in which area with onset before age 3 years?
Ability to maintain eye contact
One hallmark of autism spectrum disorders is the child's inability to maintain eye contact with another person. Parallel play is play typical of toddlers and is usually not affected. Social, not gross motor, development is affected by autism. Physical growth and development are not usually affected.
What intervention should be included in the nursing care of a child with autism spectrum disorder (ASD)?
Communicate with the child at his or her developmental level.
Children with ASD require individualized care. The nurse needs to communicate with the child at the child's developmental level. Consistent caregivers are essential for children with ASD. The same staff members should care for the child as much as possible. Children with ASD do not adapt to changing situations. The same foods should be provided to allow the child to adjust. A private room is desirable for children with ASD. Stimulation is minimized.
What suggestion by the nurse for parents regarding stuttering in children is most helpful?
Give the child plenty of time and the impression that you are not in a hurry.
Hesitancy and dysfluency should be considered a normal part of speech development. An important approach is to allow the child plenty of time to speak. Promising rewards for proper speech places additional pressure on the child. Encouraging the child to take it easy and go slow when stuttering draws attention to the dysfluency. The child needs to complete a sentence and thought without being interrupted.
What observation in a child should indicate the need for a referral to a specialist regarding a communication impairment?
At 2 years of age, the child fails to respond consistently to sounds.
If a 2-year-old child fails to respond consistently to sounds, it is an indication for referral to a specialist regarding communication impairment. At age 3 years, the child failing to use sentences of three words would be an indication for referral; impaired sentence structure would be seen in a 5-year-old child and poor voice quality in an older child who has a communication impairment.
The nurse is performing a physical assessment on a 3-year-old child. The parents state that the child excessively rubs the eyes and often tilts the head to one side. What visual impairment should the nurse suspect?
Myopia, or nearsightedness
Clinical manifestations of myopia include excessive eye rubbing, head tilting, difficulty reading, headaches, and dizziness. Strabismus, astigmatism, and hyperopia have other clinical manifestations.
The community nurse is planning prevention measures designed to avoid conditions that can cause cognitive impairment. Taking folic acid supplements during pregnancy to prevent neural tube defects is which type of prevention strategy?
Primary prevention strategies are those designed to avoid conditions that cause cognitive impairment. Use of folic acid supplements during pregnancy to prevent neural tube defects is a primary prevention strategy. Secondary prevention activities are those designed to identify the condition early and initiate treatment to avert cerebral damage. Tertiary prevention strategies are those concerned with treatment to minimize long-term consequences. Rehabilitation services is an example of tertiary prevention.
The nurse is teaching a preschool child with a cognitive impairment how to throw a ball overhand. What teaching strategy should the nurse use for this child?
Demonstrate how to throw a ball overhand
Children with cognitive impairment have a deficit in discrimination, which means that concrete ideas are much easier to learn effectively than abstract ideas. Therefore, demonstration is preferable to verbal explanation, and the nurse should direct learning toward mastering a skill rather than understanding the scientific principles underlying a procedure. Demonstrating how to throw the ball is the best teaching strategy.
The camp nurse is choosing a toy for a child with cognitive impairment to play with during swimming time. What toy should the nurse choose to encourage improvement of developmental skills?
A large beach ball
Toys are selected for their recreational and educational value. For example, a large inflatable beach ball is a good water toy; encourages interactive play; and can be used to learn motor skills such as balance, rocking, kicking, and throwing. Dive rings, an inner tube, and floating ducks are not interactive toys.
The nurse is teaching feeding strategies to a parent of a 12-month-old infant with Down syndrome. What statement made by the parent indicates a need for further teaching?
I will place the food on the top of the tongue
Parents of a child with Down syndrome need to know that the tongue thrust does not indicate refusal to feed but is a physiologic response. Parents are advised to use a small but long, straight-handled spoon to push the food toward the back and side of the mouth. If food is thrust out, it should be refed. If the parent indicates placing the food on the tongue, further teaching is needed.
The nurse is counseling a pregnant 35-year-old woman about estimated risk of Down syndrome. What is the estimated risk for a woman who is 35 years of age?c
1 in 350
The estimated risk of Down syndrome for a 35-year-old woman is one in 350. One in 1200 is the risk for a 25-year-old woman, one in 900 is the risk for a 30-year-old woman, and one in 100 is the risk for a 40-year-old woman.
The nurse is teaching parents of a child with cataracts about the upcoming treatment. The nurse should give the parents what information about the treatment of cataracts?
"Cataracts require surgery to remove the cloudy lens and replace it."
Treatment for cataracts requires surgery to remove the cloudy lens and replace it (with an intraocular lens implant, removable contact lens, or prescription glasses). Treatment for glaucoma may require more than one surgery. Anisometropia is treated with corrective lenses. Myopia is corrected with biconcave lenses that focus rays on the retina.
What action should the school nurse take for a child who has a hematoma (black eye) with no hemorrhage into the anterior chamber?
Apply ice for the first 24 hours
The care for a hematoma eye injury with no hemorrhage into the anterior chamber is to apply ice for the first 24 hours. A warm moist pack should not be applied, and the child should keep the eyes closed. Referral to an ophthalmologist is recommended if hyphema (hemorrhage into the anterior chamber) is present.
The nurse is preparing an education program on hearing impairment for a group of new staff nurses. What concepts should be included? (Select all that apply.)
A child with a slight hearing loss is usually unaware of a hearing difficulty.
A clinical manifestation of a hearing impairment in children is avoidance of social interaction.
A child with a severe hearing loss may hear a loud voice if nearby.
A clinical manifestation of hearing impairment in an infant is lack of the startle reflex.
When discussing hearing impairment in children, the nurse should include information about differences in hearing losses, such as with a slight hearing loss, the child is usually unaware of a hearing difficulty, and with a severe loss, the child may hear a loud noise if it is nearby. An infant with a hearing loss may lack the startle response, and a hearing impaired child may avoid social interaction. Children with a sensorineural hearing loss would not benefit from a hearing aid. Identification of a hearing loss is imperative in the first 3 to 6 months to facilitate language and educational development for children.
The nurse understands that which gestational disorders can cause a cognitive impairment in the newborn? (Select all that apply.)
Low birth weight
Prematurity, postmaturity, and low birth weight can be causes of cognitive impairment in newborns. Physiological jaundice and large for gestational age are not associated causes of cognitive impairment in newborns.
The clinic nurse is assessing an infant. What are early signs of cognitive impairment the nurse should discuss with the health care provider? (Select all that apply.)
Head lag at 11 months of age
Unable to speak two to three words at 24 months of age
Unresponsiveness to the environment at 12 months of age
Early signs of cognitive impairment include gross motor delay (head lag should be established by 6 months, and head lag still present at 11 months is a delay), language delay (normal language development is speaking two to three words by age 12 months; if unable to speak two to three words at 24 months, that is a delay), and unresponsiveness to the environment at 12 months. No pincer grasp at 4 months of age is normal (palmar grasp is the expected finding), and colicky incidents at 3 months of age is a normal finding.
The nurse is teaching parents of a child with a cognitive impairment signs that indicate the child is developmentally ready for dressing training. What signs should the nurse include that indicate the child is developmentally ready for dressing training? (Select all that apply.)
Can follow verbal commands
Can follow physical gestures or cues
Can relate clothing to the appropriate body part
Children are considered developmentally ready for dressing training if they can sit quietly for 3 to 5 minutes (not 1 to 2) while working on a task; can follow physical gestures or cues; can follow verbal commands; and can relate clothing to the appropriate body part, such as socks to feet. As with other self-help skills, the child may not be able to master every task but should be evaluated for evidence of willingness to participate at his or her level of readiness.
The nurse is assessing a child with Down syndrome. The nurse recognizes that which are possible comorbidities that can occur with Down syndrome? (Select all that apply.)
Congenital heart defects
Respiratory tract infections
Acute megakaryoblastic leukemia
Children with Down syndrome often have multiple comorbidities, contributing to numerous other conditions. Respiratory tract infections are prevalent; when combined with cardiac anomalies, they are the chief cause of death, particularly during the first year. The incidence of leukemia is several times more frequent than expected in the general population, and in about half of the cases, the type is acute megakaryoblastic leukemia.
A child has a slight (26-40 dB) degree of hearing loss. The nurse recognizes this amount of hearing loss can have what effect? (Select all that apply.)
No speech defects
Difficulty hearing faint speech
Usually is unaware of the hearing difficulty
A child with a slight degree of hearing loss has no speech defects, may have difficulty hearing faint speech, and is usually unaware of the hearing difficulty. The ability to distinguish vowels but not consonants is an effect of severe hearing loss and being unable to understand conversational speech is an effect of moderately severe hearing loss.
What risk factors can cause a sensorineural hearing impairment in an infant? (Select all that apply.)
Childhood case of measles
Administration of amino glycosides for more than 5 days
Risk criteria for sensorineural hearing impairment in infants include bacterial meningitis; a case of measles; and administration of ototoxic medications (e.g., gentamicin, tobramycin, kanamycin, streptomycin), including but not limited to the aminoglycosides, for more than 5 days. Cat scratch disease and a childhood case of chicken pox are not risk factors that can cause a sensorineural hearing impairment.
The nurse is teaching parents the signs of a hearing impairment in infants. What should the nurse include as signs? (Select all that apply.)
Lack of a startle reflex to a loud sound
Failure to localize a sound by 6 months of age
Response to loud noise as opposed to the voice
The fencing reflex is elicited when the infant is placed on his or her back; it does not indicate a hearing impairment. Awakening by a loud environmental noise is a normal response.
The nurse is teaching parents the signs of a hearing impairment in a child. What should the nurse include as signs? (Select all that apply.)
Yelling to express pleasure
Asking to have statements repeated
Foot stamping for vibratory sensation
Failure to develop intelligible speech by 24 months of age
Signs of a hearing impairment in a child include yelling to express pleasure, asking to have statements repeated, foot stamping for vibratory sensation, and failure to develop intelligible speech by age 24 months. The child's behavior is shy, not outgoing.
The nurse should plan which actions to assist the stuttering child? (Select all that apply.)
Set a good example by speaking clearly
Give the child plenty of time to finish sentences
Look directly at the child while he or she is speaking
Actions to be encouraged to help the stuttering child include setting a good example by speaking clearly, giving the child plenty of time to finish sentences, and looking directly at the child while he or she is speaking. Asking the child to stop and start over and promising a reward for proper speech are actions to be avoided with stuttering children.
The nurse should plan which actions to facilitate lipreading for a child with a hearing impairment? (Select all that apply.)
Face the child directly
Speak at eye level
Keep sentences short
Establish eye contact and show interest
To facilitate lipreading, the nurse should plan to face the child directly, speak at eye level, keep sentences short, and establish eye contact and show interest. The nurse should plan to speak at a slow rate, not a fast one.
What are indications for a referral regarding a communication impairment in a school-age child? (Select all that apply.)
Barely audible voice quality
Vocal pitch inappropriate for age
Distortion of sounds after age 7 years
Barely audible voice quality, vocal pitch inappropriate for age, and distortion of sounds after age 7 years are indications for a referral regarding a communication impairment. Intonation noted while speaking and maintaining a rhythm while speaking are normal characteristics of speech.
Ability to see objects clearly at close range but not at a distance
Ability to see objects at a distance but not at a close range
Unequal curvatures in refractive apparatus
Different refractive strength in each eye
Reduced visual acuity in one eye
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