Nokea
A 15-year-old has been admitted to the hospital with the diagnosis of acute lymphocytic leukemia. Which of the following signs and symptoms require the most immediate nursing intervention?
- A. Fatigue and anorexia.
- B. Fever and petechiae.
- C. Swollen neck lymph glands and lethargy.
- D. Enlarged liver and spleen.
Correct Answer: B
Rationale: Fever and petechiae indicate infection and bleeding risk, requiring urgent intervention in leukemia due to immunosuppression and low platelets.
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After teaching a child with leukemia scheduled for a bone marrow aspiration about the procedure, the nurse determines that the teaching has been successful when the child identifies which of the following as the site for the aspiration?
- A. Right lateral side of the right wrist.
- B. Middle of the chest.
- C. Distal end of the thigh.
- D. Back of the hipbone.
Correct Answer: D
Rationale: Bone marrow aspiration is typically performed at the iliac crest (hipbone). Other sites are incorrect.
To assess a 9-year-old's social development, the nurse asks the parent if the child:
- A. Thinks independently.
- B. Is able to organize and plan.
- C. Has a best friend.
- D. Enjoys active play.
Correct Answer: C
Rationale: Having a best friend indicates healthy social development at 9 years.
When developing the teaching plan for the mother of a 2-year-old child diagnosed with babies, which do not be the following points should the nurse expect to include?
- A. The floors of the house should be cleaned with a damp mop.
- B. The child should be held frequently.
- C. Itching should cease in a few days.
- D. The entire family should be treated.
Correct Answer: D
Rationale: The question likely refers to scabies (miswritten as 'babies'). Scabies requires treatment of all household members to prevent reinfestation. Damp mopping is less relevant, frequent holding may spread mites, and itching may persist post-treatment.
The father of a 16-month-old child calls the clinic because the child has a low-grade fever, cold symptoms, and a hoarse cough. Which of the following should the nurse suggest that the father do?
- A. Offer extra fluids frequently.
Correct Answer: A
Rationale: Offering extra fluids frequently helps keep the child hydrated and may soothe the throat, alleviating symptoms of croup.
Which statement by the mother of a child with Wilms' tumor tells the nurse that the mother understands what stage II tumor means?
- A. The tumor has extended beyond the kidney but was completely removed.
- B. Although the tumor was in the kidney, it has spread to the lung, liver, and bone.
- C. The tumor has extended outside the kidney to the lungs and the liver.
- D. The tumor was solely located in the kidney but it was totally removed.
Correct Answer: A
Rationale: Stage II indicates removal beyond kidney.