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A child with leukemia is admitted for chemotherapy, and the nursing diagnosis 'altered nutrition, less than body requirements related to anorexia, nausea, and vomiting' is identified. Which intervention should the nurse include in this child's plan of care?
- A. Encourage a variety of large portions of food at every meal.
- B. Allow the child to eat any food desired and tolerated.
- C. Recommend eating the food as siblings eat at home.
- D. Restrict food brought from fast-food restaurants.
Correct Answer: B
Rationale: Allowing the child to eat any food desired and tolerated is the most appropriate intervention in this scenario. Anorexia, nausea, and vomiting are common side effects of chemotherapy, which can lead to altered nutrition. Allowing the child to choose foods they desire and can tolerate can help improve their nutritional intake during this challenging time.
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What action should the nurse implement when the infusion is complete for a 16-year-old with acute myelocytic leukemia receiving chemotherapy via an implanted medication port at the outpatient oncology clinic?
- A. Administer Zofran
- B. Obtain blood samples for RBCs, WBCs, and platelets
- C. Flush the mediport with saline and heparin solution
- D. Initiate an infusion of normal saline
Correct Answer: C
Rationale: After completing the chemotherapy infusion via the implanted medication port, the nurse should flush the mediport with saline and heparin solution. This action helps prevent clot formation in the port, ensuring its patency for future use and reducing the risk of complications associated with catheter occlusion.
A 3-year-old child is brought to the clinic by the parents who are concerned that the child is not yet potty trained. What is the nurse's best response?
- A. Most children are potty trained by this age, so you should be concerned
- B. Every child develops at their own pace. Let's discuss some strategies to help
- C. Your child may need to be evaluated for developmental delays
- D. It's best to force your child to use the potty to encourage training
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Following a motor vehicle collision, a 3-year old girl has a spica cast applied. Which toy is best for the nurse for this 3 year old child?
- A. Duck that squeaks.
- B. Fashion doll and clothes.
- C. Set of cloth and hand puppets.
- D. Hand held video game.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
During a routine physical exam, a male adolescent client tells the nurse, 'sometimes, my mother gets angry because I want to be with my own friends.' What is the best initial response by the nurse?
- A. Offer reassurance that his mother's concern is normal
- B. Determine if his friends are engaged in unsafe behaviors
- C. Ask about the client's response to his mother's anger
- D. Offer to discuss his concerns with his mother
Correct Answer: C
Rationale: When a client expresses concerns about family dynamics, it is important to explore their feelings and reactions to the situation. By asking about the client's response to his mother's anger, the nurse can gain insight into the client's emotions, thoughts, and coping mechanisms. Understanding these aspects is crucial in providing appropriate support and guidance.
When caring for a 5-year-old child with a history of seizures who suddenly begins to have a tonic-clonic seizure, what should the nurse do first?
- A. Administer oxygen
- B. Insert an oral airway
- C. Turn the child to the side
- D. Start an IV line
Correct Answer: C
Rationale: During a tonic-clonic seizure, the priority action is to turn the child to the side. This helps maintain an open airway and prevents aspiration of secretions or vomitus. It also helps in keeping the airway clear and promotes safety during the seizure episode. Administering oxygen, inserting an oral airway, and starting an IV line are important interventions but should follow the initial step of positioning the child to prevent airway obstruction.