Nokea
A 12-year-old with leukemia is receiving cyclophosphamide (Cytoxan). The nurse should assess for the adverse effect of:
- A. Photosensitivity.
- B. Ataxia.
- C. Cystitis.
- D. Cardiac arrhythmias.
Correct Answer: C
Rationale: Cyclophosphamide causes hemorrhagic cystitis, requiring monitoring. Other effects are less common.
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An adolescent with insulin-dependent diabetes is being taught the importance of rotating the sites of insulin injections. The nurse should judge that the teaching was successful when the adolescent identifies which of the following as a result of using the same site?
- A. Unstruction of the fat tissue and poor absorption.
- B. Destruction of nerves and painful neuritis.
- C. Destruction of the tissue and too-rapid insulin uptake.
- D. Development of resistance to insulin and need for increased amounts.
Correct Answer: A
Rationale: Repeated injections at the same site cause lipodystrophy, leading to poor insulin absorption. Nerve damage, rapid uptake, or insulin resistance are not primary consequences.
In planning the discharge for a newborn diagnosed with torticollis (wry neck), the nurse should:
- A. Teach the parent the side effects of botulinum toxin (BOTOX).
- B. Coordinate outpatient physical therapy.
- C. Verify the date for corrective surgery.
- D. Demonstrate the use of positioning wedges for sleep.
Correct Answer: B
Rationale: Physical therapy is the most important part of the child's plan of care. Most cases of torticollis respond to gentle stretching exercises, which can be taught to parents and continued at home.
A nurse walks into the room just as a 10-month-old infant places an object in his mouth and starts to choke. After opening the infant's mouth, which of the following should the nurse do next to clear the airway?
- A. Use blind finger sweeps.
- B. Deliver back slaps and chest thrusts.
- C. Apply four subdiaphragmatic abdominal thrusts.
- D. Attempt to visualize the object.
Correct Answer: B
Rationale: For a 10-month-old choking, delivering back slaps and chest thrusts is the recommended method to dislodge a foreign body, as per pediatric guidelines.
A child with spastic cerebral palsy is to begin botulinum toxin type A (Botox) injections. Which treatment goals should the health care team set for the child related to Botox? Select all that apply.
- A. Improved nutritional status.
- B. Improved motor function.
- C. Enhanced self-esteem.
- D. Reduced caregiver strain and improved selfcare.
- E. Decreased speech impediments.
Correct Answer: B,D
Rationale: Botox injections in spastic cerebral palsy aim to reduce muscle spasticity, improving motor function and easing caregiving tasks, thus reducing caregiver strain.
A 10-year-old child proudly tells the nurse that brushing and flossing her teeth is her responsibility. The nurse interprets this statement as indicating which of the following about the child?
- A. She is too young to be given this responsibility.
- B. She is most likely capable of this responsibility.
- C. She should have assumed this responsibility much sooner.
- D. She is probably just exaggerating the responsibility.
Correct Answer: B
Rationale: A 10-year-old is capable of taking responsibility for personal hygiene tasks like brushing teeth.