Nokea
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.
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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.
Which statement by a mother may indicate a cause for her 9-month-old's iron deficiency anemia?
- A. Formula is so expensive. We switched to regular milk right away.'
- B. She almost never drinks water.'
- C. She doesn't really like peaches or pears, so we stick to bananas for fruit.'
- D. I give her a piece of bread now and then. She likes to chew on it.'
Correct Answer: A
Rationale: Because cow's milk contains very little iron, infants should drink iron-fortified formula for the first year of life.
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.
A 2-year-old child has been diagnosed with hemophilia A. What information should the nurse include in a teaching plan about home care?
- A. If bleeding occurs, apply pressure, ice, elevate, and rest the extremity.
- B. Children's aspirin in lowered doses may be given for joint discomfort.
- C. A firm, dry toothbrush should be used to clean teeth at least twice a day.
- D. Do not permit interactive play with other children.
Correct Answer: A
Rationale: When bleeding occurs, the traditional approach is to follow RICE - rest, ice, compression, and elevation.
Why would the nurse urge the family of a dying 12-year-old boy to include his 8-year-old sister in care? (Select all that apply.)
- A. She will feel less neglected by the parents.
- B. She can make amends for past hostilities to her brother.
- C. She will feel increased helplessness.
- D. She can express her feelings through care.
- E. She can experience being supportive of her parents and brother.
Correct Answer: A,B,D,E
Rationale: Including the sibling in care helps reduce feelings of neglect, allows expression of feelings, and fosters a sense of support and connection.