Nokea
The nurse is assessing a child with leukemia who is receiving chemotherapy. Which finding indicates a potential complication requiring immediate action?
- A. A temperature of 100.4°F (38°C).
- B. A heart rate of 90 beats per minute.
- C. A platelet count of 150,000/mm³.
- D. A white blood cell count of 5,000/mm³.
Correct Answer: A
Rationale: A fever of 100.4°F in a child on chemotherapy suggests possible infection, a life-threatening complication due to immunosuppression, requiring immediate action.
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An 8-year-old child does well after infratentorial tumor removal and is transferred back to the pediatric unit. Although she had been told about having her head shaved, she becomes upset. After exploring the child's feelings, which action should the nurse take?
- A. Ask the child if she'd like to wear a hat.
- B. Reassure the child that her hair will grow back.
- C. Explain to the child's parents that her reaction is normal.
- D. Suggest that the parents buy the child a wig as a surprise.
Correct Answer: A
Rationale: Offering a hat empowers the child to cope with her appearance change, addressing her distress directly.
A parent brings a 4-month-old to the clinic for a regular well visit and expresses concern that the infant is not developing appropriately. Which findings in the infant would indicate the need for further developmental screening?
- A. Has no interest in peek-a-boo games.
- B. Does not turn front to back.
- C. Does not babble.
- D. Continues to have head lag.
Correct Answer: D
Rationale: Head lag at 4 months suggests delayed motor development, requiring further evaluation.
Which of the following should the nurse expect to observe in an infant with intussusception before surgical intervention?
- A. Fever and lethargy.
- B. Currant jelly stools.
- C. Frequent loose stools.
- D. Increased appetite.
Correct Answer: B
Rationale: Currant jelly stools are a classic sign of intussusception due to mucosal bleeding.
Several high-school seniors are referred to the school nurse because of suspected alcohol misuse. When the nurse assesses the situation, what would be most important to determine?
- A. What they know about the legal implications of drinking.
- B. The type of alcohol they usually drink.
- C. The reasons they choose to use alcohol.
- D. When and with whom they use alcohol.
Correct Answer: C
Rationale: Understanding the reasons for alcohol use helps address underlying issues and tailor interventions.
A 10-year old child is admitted to the hospital with complications related to chickenpox. The nurse should do which of the following to prevent the transmission of the infection to other children on the unit? Select all that apply.
- A. Place the child on contact isolation.
- B. Wear a gown, mask, and gloves before entering the room.
- C. Place the child in a room with a 10-year-old who has had chickenpox.
- D. Place the child in a negative air-flow room.
- E. Maintain isolation until lesions have disappeared.
Correct Answer: A,B,C,E
Rationale: Chickenpox requires contact and airborne precautions (gown, mask, gloves) and isolation until lesions crust. Rooming with an immune child reduces risk. Negative airflow is for diseases like tuberculosis.