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When assessing a child with leukemia, which clinical manifestations should the nurse anticipate?
- A. Petechiae, fever, fatigue
- B. Headache, papilledema, irritability
- C. Muscle wasting, weight loss, fatigue
- D. Decreased intracranial pressure, psychosis, confusion
Correct Answer: A
Rationale: The correct answer is A: Petechiae, fever, fatigue. Children with leukemia commonly present with petechiae (due to low platelet count), fever (due to infection), and fatigue (due to anemia), which are classic manifestations of the disease. Option B is incorrect because headache, papilledema, and irritability are more indicative of increased intracranial pressure, not leukemia. Option C is incorrect as muscle wasting and weight loss are not typical initial manifestations of leukemia in children. Option D is incorrect as decreased intracranial pressure, psychosis, and confusion are not commonly associated with leukemia.
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What are signs and symptoms of a possible kidney transplant rejection in a child? (Select all that apply.)
- A. Fever
- B. Hypotension
- C. All are applicable
- D. Swelling and tenderness of graft area
Correct Answer: B
Rationale: Signs of kidney transplant rejection include fever, diminished urinary output, and swelling/tenderness in the graft area. These symptoms indicate that the body may be rejecting the transplanted organ, requiring immediate medical attention.
A preschool-age boy presents to the outpatient clinic for a sore throat. In the child's mind, which is the most likely cause for the sore throat?
- A. Being exposed to a classmate with strep throat
- B. Not eating the right foods
- C. Not taking daily vitamins
- D. Yelling at sibling for being annoying
Correct Answer: D
Rationale: The correct answer is D. Preschool-age children often attribute illness to their actions, like yelling at a sibling or not following instructions. They may not understand medical causes such as exposure to infections like strep throat (choice A), dietary factors (choice B), or vitamin deficiencies (choice C). It is common for young children to connect symptoms to recent behaviors or events within their limited understanding.
During a well-child checkup, the parent of a 5-year-old child reports the child seems much smaller than the 2 older siblings did at this same age. A review of the medical record reveals that the child is 44 inches tall and weighs 42 pounds. What information should be included in the response by the nurse?
- A. The weight of your child at this time is within normal limits for this age but the child is moderately taller than other children this age.
- B. Your child is within the acceptable range for height but the child is significantly smaller in weight for this age.
- C. Your child is within normal limits for weight but the child is slightly shorter in stature than other children this age.
- D. Your child is slightly taller than other children this age but the child's weight is normal.
Correct Answer: D
Rationale: The correct answer is D. The child is slightly taller than average, but the weight is within normal limits. This information should be reassuring to the parent and provides insights into normal growth patterns. Choice A is incorrect as it inaccurately states that the child is taller than other children this age. Choice B is incorrect because the child's weight is actually within normal limits. Choice C is incorrect as it inaccurately states that the child is shorter in stature than other children this age.
The nurse is caring for an infant after a cleft lip repair. Which of these measures should be included in the plan of care?
- A. Position prone
- B. Provide fluids from a cup
- C. Position supine
- D. Avoid elbow restraints
Correct Answer: C
Rationale: The correct measure that should be included in the plan of care for an infant after a cleft lip repair is to position the infant supine. Placing the infant in a supine position helps protect the surgical site from injury and promotes proper healing. Choice A, 'Position prone,' is incorrect as placing the infant prone can put pressure on the surgical site and hinder healing. Choice B, 'Provide fluids from a cup,' is not directly related to the surgical care of a cleft lip repair. Choice D, 'Avoid elbow restraints,' is not specific to the postoperative care of a cleft lip repair.
What is an appropriate nursing intervention for a child with minimal change nephrotic syndrome (MCNS) who has scrotal edema?
- A. Place an ice pack on the scrotal area.
- B. Place the child in an upright sitting position.
- C. Elevate the scrotum with a rolled washcloth.
- D. Place a warm moist pack to the scrotal area.
Correct Answer: C
Rationale: Elevating the scrotum with a rolled washcloth helps reduce edema by promoting fluid drainage. Ice packs are not recommended due to the risk of frostbite, and warm moist packs are not typically used for this purpose. An upright position does not specifically address the edema.