Nokea
On admission, a child with leukemia has widespread purpura and a platelet count of 19,000/mm?³. What is the priority nursing intervention?
- A. Assessing neurological status
- B. Inserting an intravenous line
- C. Monitoring vital signs during platelet transfusions
- D. Providing family education about how to prevent bleeding
Correct Answer: A
Rationale: When platelets are low, the greatest danger is spontaneous intracranial bleeding. Neurological assessments are therefore a priority of care.
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The nurse is teaching the parents of a young child with iron deficiency anemia about nutrition. What food would the nurse emphasize as being a rich source of iron?
- A. An egg white
- B. Cream of Wheat
- C. A banana
- D. A carrot
Correct Answer: B
Rationale: Good nutritional sources of iron include boiled egg yolk, liver, green leafy vegetables, Cream of Wheat, dried fruits, beans, nuts, and whole-grain breads.
What should be included in the nursing care of a 12-year-old child receiving radiation therapy for Hodgkin's disease? (Select all that apply.)
- A. Application of sunblock
- B. Appetite stimulation
- C. Conservation of energy
- D. Provision for expressions of anger
- E. Preparation for premature sexual development
Correct Answer: A,B,C,D
Rationale: Sunblock prevents skin burning, and addressing low energy, anorexia, and anger are key aspects of care for a child receiving radiation.
The nurse, caring for a child receiving chemotherapy, notes that the child's abdomen is firm and slightly distended. There is no record of a bowel movement for the last 2 days. What do these assessment findings suggest?
- A. Peripheral neuropathy
- B. Stomatitis
- C. Myelosuppression
- D. Hemorrhage
Correct Answer: A
Rationale: Peripheral neuropathy may be signaled by severe constipation resulting from decreased nerve sensations in the bowel.
What would the nurse include in a teaching plan about mouth care of a child receiving chemotherapy?
- A. Use commercial mouthwash.
- B. Clean teeth with a soft toothbrush.
- C. Avoid use of a Water-Pik.
- D. Inspect the mouth weekly for ulcerations.
Correct Answer: B
Rationale: A soft toothbrush reduces capillary damage and mucous membrane breakdown and prevents bleeding and infection.
A 6-year-old child with leukemia asks, 'Who will take care of me in heaven?' What is the best response by the nurse?
- A. Who do you think will take care of you?'
- B. Your grandparents and God will take care of you.'
- C. Your mom will know more about that than I do.'
- D. Why are you asking me that?'
Correct Answer: A
Rationale: This response gives the child an opportunity to verbalize his or her feelings and concerns, whereas closed responses shut off communication.