Nokea
The most recent blood count for a child who received chemotherapy last week shows neutropenia. What is the priority nursing diagnosis for this child?
- A. Risk for infection
- B. Risk for hemorrhage
- C. Altered skin integrity
- D. Disturbance in body image
Correct Answer: A
Rationale: The child with neutropenia is at risk for infection.
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An adolescent is diagnosed with Hodgkin's disease. Lymph nodes on both sides of her diaphragm have been found to be involved, including cervical and inguinal nodes. Which disease stage is this?
- A. I
- B. II
- C. III
- D. IV
Correct Answer: C
Rationale: Lymph node regions on both sides of the diaphragm are consistent with a diagnosis of stage-III Hodgkin's disease.
The nurse notes that a 4-year-old child's gums bleed easily and he has bruising and petechiae on his extremities. Which lab value is consistent with these symptoms?
- A. Platelet count of 25,000/mm?³
- B. Hemoglobin level of 8 g/dL
- C. Hematocrit level of 36%
- D. Leukocyte count of 14,000/mm?³
Correct Answer: A
Rationale: The normal platelet count is 150,000 to 400,000/mm?³. This finding is very low, indicating an increased bleeding potential.
The nurse is caring for a child with a low platelet count. What skin assessments would alert the nurse to bleeding? (Select all that apply.)
- A. Petechiae
- B. Purpura
- C. Ecchymosis
- D. Hematoma
- E. Lymphadenopathy
Correct Answer: A,B,C,D
Rationale: The reduction or destruction of platelets in the body interferes with the clotting mechanism, leading to skin lesions such as petechiae, purpura, ecchymosis, and hematoma.
A child has just been diagnosed with acute lymphoblastic leukemia. What is the result of an overproduction of immature white blood cells in the bone marrow?
- A. Decreased T-cell production
- B. Decreased hemoglobin
- C. Increased blood clotting
- D. Increased susceptibility to infection
Correct Answer: D
Rationale: An overproduction of immature white blood cells increases the child's susceptibility to infection.
The child receiving a transfusion complains of back pain and itching. What is the best initial action by the nurse?
- A. Notify the charge nurse.
- B. Disconnect intravenous lines immediately.
- C. Give diphenhydramine (Benadryl).
- D. Clamp off blood and keep line open with normal saline.
Correct Answer: D
Rationale: If a blood transfusion reaction occurs, the first action is to stop the blood infusion, keep the line open with normal saline, and notify the charge nurse.