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Which of the following statements should the nurse use to describe to the parents why their child with leukemia is at risk for infections?
- A. Play activities are too strenuous.
- B. Vitamin C intake is reduced over a period of time.
- C. The number of red blood cells is inadequate for carrying oxygen.
- D. Immature white blood cells are incapable of handling an infectious process.
Correct Answer: D
Rationale: Immature white blood cells in leukemia cannot effectively fight infections, increasing risk. Other options are unrelated.
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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.
Assessment of a school-age child with Guillain-Barré syndrome reveals absent gag and cough reflexes. Which of the following nursing diagnoses should receive the highest priority during the acute phase?
- A. Risk for infection due to altered immune system.
- B. Ineffective breathing pattern related to neuromuscular impairment.
- C. Impaired swallowing related to neuromuscular impairment.
- D. Total urinary incontinence related to fluid losses.
Correct Answer: B
Rationale: Absent gag and cough reflexes increase the risk of respiratory compromise, making ineffective breathing pattern the highest priority.
The mother of a toddler hospitalized for episodes of diarrhea reports that when her toddler cannot have things the way she wants, she throws her legs and arms around, screams, and cries. The mother says, "I don't know what to do?" After teaching the mother about ways to manage this behavior, which of the following statements indicates that the nurse's teaching was successful?
- A. Next time she screams and throws her legs, I'll ignore the behavior.
- B. I'll allow her to have what she wants once in a while.
- C. I'll explain why she cannot have what she wants.
- D. When she behaves like this, I'll tell her that she is being a bad girl.
Correct Answer: A
Rationale: Ignoring tantrums reinforces calm behavior without rewarding outbursts.
The nurse is assessing a child with suspected appendicitis. Which physical finding supports this diagnosis?
- A. Rebound tenderness in the right lower quadrant.
- B. Soft, non-tender abdomen.
- C. Frequent bowel movements.
- D. Generalized abdominal bloating.
Correct Answer: A
Rationale: Rebound tenderness is a key sign of appendicitis due to peritoneal irritation.
After teaching the parents about the cause of ringworm of the scalp (tinea capitis), which of the following, if stated by the father, indicates successful teaching?
- A. It results from overexposure to the sun.
- B. It's caused by infestation with a mite.
- C. It's a fungal infection of the scalp.
- D. It's an allergic reaction.
Correct Answer: C
Rationale: Tinea capitis is caused by a fungal infection, not mites, sun exposure, or allergies.