Nokea
What is the priority nursing intervention for a child with a diagnosis of acute lymphoblastic leukemia (ALL) receiving chemotherapy?
- A. Preventing infection
- B. Administering chemotherapy
- C. Providing nutritional support
- D. Monitoring fluid intake
Correct Answer: A
Rationale: The correct answer is A: Preventing infection. When caring for a child with acute lymphoblastic leukemia (ALL) undergoing chemotherapy, the top priority is to prevent infection. Chemotherapy suppresses the immune system, making the child more susceptible to infections. By implementing infection control measures such as hand hygiene, aseptic techniques, and environmental cleanliness, the nurse can help protect the child from potentially life-threatening infections. Administering chemotherapy (choice B) is important but not the priority over preventing infection. Providing nutritional support (choice C) and monitoring fluid intake (choice D) are essential aspects of care but take a back seat to preventing infection in this scenario.
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The nurse is teaching a group of students about myelination in a child. Which statement by the students indicates that the teaching was successful?
- A. Myelination continues into adolescence and beyond.
- B. The process occurs in a cephalocaudal (head-to-toe) pattern.
- C. Myelination decreases the speed of nerve impulses.
- D. Myelination decreases the specificity of nerve impulses.
Correct Answer: B
Rationale: The correct answer is B. Myelination occurs in a cephalocaudal (head-to-toe) pattern, improving nerve function progressively. Choice A is incorrect as myelination continues into adolescence and beyond, not just during childhood. Choice C is incorrect because myelination actually increases the speed of nerve impulses rather than decreasing it. Choice D is incorrect as myelination enhances the specificity of nerve impulses, making them more efficient and precise rather than less specific.
After instituting ordered measures to reduce the fever in a 3-year-old with fever and vomiting, what nursing action is most important for the nurse in the emergency department to take?
- A. Preventing shivering
- B. Restricting oral fluids
- C. Measuring output hourly
- D. Taking vital signs hourly
Correct Answer: A
Rationale: Preventing shivering is crucial in this situation as it can increase the body temperature and counteract the effects of antipyretic measures aimed at reducing the fever. Shivering generates heat, potentially worsening the fever. Restricting oral fluids (Choice B) is not appropriate as fluid intake is important to prevent dehydration, especially in a child who has been vomiting. Measuring output hourly (Choice C) and taking vital signs hourly (Choice D) are important nursing actions but not as critical as preventing shivering in this scenario. Therefore, the most important nursing action is to prevent shivering to aid in fever reduction and management.
A home care nurse is visiting a family for the first time. The 4-week-old infant had surgery for exstrophy of the bladder and creation of an ileal conduit soon after birth. When the nurse arrives, the mother appears tired, and the baby is crying. After an introduction, which is the most appropriate statement by the nurse?
- A. "Tell me about your daily routine."
- B. "You look tired. Is everything alright?"
- C. "When was the last time the baby had a bottle?"
- D. "Oh, it looks like you two are having a bad day."
Correct Answer: A
Rationale: Asking about the daily routine is the most appropriate statement by the nurse in this scenario. It allows the nurse to gather important information about the family's schedule, feeding patterns, and overall care routine for the infant. This open-ended question helps the nurse assess the family's situation comprehensively and identify any areas where support may be needed. Choices B, C, and D are less appropriate as they do not focus on gathering relevant information about the family's routine and needs but rather make assumptions or ask about specific isolated events.
When working with a couple at risk of bearing a child with a genetic abnormality, what is most important for the nurse to incorporate into the plan of care?
- A. Gathering information from at least three generations
- B. Informing the couple of the need for a wide range of information
- C. Maintaining the confidentiality of the information
- D. Presenting the information in a nondirective manner
Correct Answer: D
Rationale: When counseling a couple at risk of genetic abnormalities, it is crucial to present information in a nondirective manner. This approach allows the couple to make informed decisions without feeling pressured or influenced. Gathering information from at least three generations (Choice A) may be relevant for genetic counseling but is not the most critical aspect in this scenario. Informing the couple of the need for a wide range of information (Choice B) is too general and does not address the specific approach needed in this situation. Maintaining the confidentiality of the information (Choice C) is important but not the top priority compared to presenting information in a nondirective manner.
One principle to be followed for children with type 1 diabetes is to provide for the variability of the child's activity. What should the nurse teach the child about how to compensate for increased physical activity?
- A. Eat more food when planning to exercise more than usual.
- B. Take oral, not injectable insulin, on days of heavy exercise.
- C. Take insulin in the morning when extra exercise is anticipated.
- D. Eat foods that contain sugar to compensate for the extra exercise.
Correct Answer: A
Rationale: The correct answer is to eat more food when planning to exercise more than usual. Increased physical activity requires more energy, so additional food intake is necessary to compensate for the increased energy expenditure. This helps maintain blood sugar levels within the target range. Choice B is incorrect because the mode of insulin administration does not change based on physical activity; the type and dose of insulin remain the same unless adjusted by a healthcare provider. Choice C is incorrect because insulin timing should not be adjusted solely based on anticipated exercise; consistent timing of insulin doses is crucial for stable blood sugar control. Choice D is incorrect because consuming foods with sugar may lead to unstable blood sugar levels and is not the recommended way to compensate for extra exercise, as it can result in sudden spikes and drops in blood glucose levels, affecting overall diabetes management.