Nokea
A child with a diagnosis of leukemia is receiving chemotherapy. What is the most important nursing intervention?
- A. Monitor for signs of infection
- B. Monitor for signs of bleeding
- C. Monitor for signs of dehydration
- D. Monitor for signs of pain
Correct Answer: A
Rationale: The correct answer is to monitor for signs of infection. When a child is undergoing chemotherapy, their immune system is compromised, making them more susceptible to infections. Monitoring for signs of infection is crucial to promptly identify and treat any potential infections. Choices B, C, and D are incorrect because although monitoring for bleeding, dehydration, and pain are important aspects of care, the priority for a child receiving chemotherapy is to prevent and detect infections due to their increased vulnerability.
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An 8-year-old child with the diagnosis of meningitis is to have a lumbar puncture. What should the nurse explain is the purpose of this procedure?
- A. To measure the pressure of cerebrospinal fluid
- B. To obtain a sample of cerebrospinal fluid for analysis
- C. To relieve intracranial pressure
- D. To assess the presence of infection in the spinal fluid
Correct Answer: B
Rationale: The primary purpose of a lumbar puncture is to obtain a sample of cerebrospinal fluid for analysis. This sample helps in diagnosing conditions such as meningitis by evaluating the presence of pathogens or abnormalities in the cerebrospinal fluid. Measuring the pressure of cerebrospinal fluid (Choice A) is not the main objective of a lumbar puncture, although it can be done during the procedure. Relieving intracranial pressure (Choice C) is not the direct purpose of a lumbar puncture, as other interventions are typically used for this purpose. Assessing the presence of infection in the spinal fluid (Choice D) is related to the overall goal of obtaining a sample for analysis, making it a secondary outcome of the procedure.
Which best describes a full-thickness (third-degree) burn?
- A. Erythema and pain
- B. Skin showing erythema followed by blister formation
- C. Destruction of all layers of skin evident with extension into subcutaneous tissue
- D. Destruction injury involving underlying structures such as muscle, fascia, and bone
Correct Answer: C
Rationale: A full-thickness (third-degree) burn involves the destruction of all layers of skin, including the epidermis, dermis, and extending into the subcutaneous tissue. This type of burn results in significant tissue damage and can appear pale, charred, or leathery. Choice A is incorrect as erythema and pain are more characteristic of superficial burns. Choice B describes a partial-thickness burn where the skin shows erythema followed by blister formation, involving the epidermis and part of the dermis. Choice D is incorrect as it describes a deeper type of injury involving structures beyond the skin layers, such as muscle, fascia, and bone, which is not specific to a full-thickness burn.
A nurse is caring for an infant born with exstrophy of the bladder. What does the nurse determine is the greatest risk for this infant?
- A. Infection
- B. Dehydration
- C. Urinary retention
- D. Intestinal obstruction
Correct Answer: A
Rationale: Infection is the greatest risk for an infant with exstrophy of the bladder due to the exposure of the bladder and surrounding tissues. The exposed bladder increases the risk of infection as it lacks the protective covering of the skin. Dehydration (Choice B) may occur but is not the greatest risk compared to infection. Urinary retention (Choice C) is less likely due to the nature of the condition. Intestinal obstruction (Choice D) is not directly associated with exstrophy of the bladder.
What finding would the nurse expect to assess in a child with hypothyroidism?
- A. Nervousness
- B. Heat intolerance
- C. Smooth velvety skin
- D. Weight gain
Correct Answer: D
Rationale: In a child with hypothyroidism, weight gain is a typical finding due to the slowed metabolism associated with the condition. This occurs because thyroid hormone levels are insufficient to regulate metabolism effectively. Choices A, B, and C are not typically associated with hypothyroidism. Nervousness is more commonly seen in conditions like hyperthyroidism, where there is an excess of thyroid hormones. Heat intolerance may be seen in hyperthyroidism as well, where the body's metabolism is increased. Smooth velvety skin is a characteristic finding in conditions like Cushing's syndrome, where there is excess cortisol production.
An 8-year-old child diagnosed with meningitis is to undergo a lumbar puncture. What should the nurse explain is the purpose of this procedure?
- A. To measure the pressure of cerebrospinal fluid
- B. To obtain a sample of cerebrospinal fluid for analysis
- C. To relieve intracranial pressure
- D. To assess the presence of infection in the spinal fluid
Correct Answer: B
Rationale: A lumbar puncture is performed to obtain a sample of cerebrospinal fluid for analysis. This fluid is then examined for signs of infection, bleeding, or other abnormalities. Measuring the pressure of cerebrospinal fluid is typically done during the procedure itself, but it is not the primary purpose of the lumbar puncture. While a lumbar puncture can indirectly help relieve intracranial pressure by removing excess cerebrospinal fluid, this is not its primary purpose. Assessing the presence of infection in the spinal fluid is part of the analysis that follows the collection of the sample, making it a secondary outcome of the procedure.