Question

A nurse is planning care for a preschooler.

Answer 1

Correct Answers:

Alopecia
Tumor lysis syndrome
Hemorrhage
Peripheral neuropathy

Rationale :

🔷 Alopecia is a common side effect of chemotherapy, especially agents like vincristine and doxorubicin, which target rapidly dividing cells.

🔷 These agents damage hair follicle cells, leading to hair loss typically within 1–2 weeks of treatment initiation.

🔷 The psychosocial impact of alopecia is significant in pediatric clients and must be addressed through therapeutic support.

🔷 Scalp cooling or discussions about hair coverings can help reduce distress.

🔷 Parents should be educated that hair typically regrows after the treatment phase.

Tumor Lysis Syndrome (TLS)

🔷 TLS is a potentially life-threatening emergency associated with rapid destruction of malignant cells, particularly in leukemia during induction therapy.

🔷 The breakdown of tumor cells releases potassium, phosphate, and uric acid, leading to electrolyte imbalances and renal failure.

🔷 This child is in the induction phase of chemotherapy, which is the highest risk period for TLS.

🔷 Prophylactic measures like hydration and allopurinol may be implemented to reduce risk.

🔷 Nurses must monitor for signs like nausea, vomiting, lethargy, and cardiac arrhythmias.

Hemorrhage

🔷 The child’s platelet count is 120,000/mm³, below the normal range (150,000–400,000), placing them at risk for bleeding.

🔷 Thrombocytopenia is a common complication of chemotherapy due to bone marrow suppression.

🔷 The nurse should monitor for signs of bleeding gums, petechiae, hematuria, and bruising.

🔷 Injury prevention measures are critical, including soft toothbrush use and avoiding IM injections.

🔷 The nurse should ensure availability of platelet transfusion if levels fall further.

Peripheral Neuropathy

🔷 Vincristine, a chemotherapy drug used in this client’s treatment, commonly causes peripheral neuropathy.

🔷 Neuropathy results from nerve damage, leading to tingling, numbness, or weakness, often in the hands and feet.

🔷 In children, this may manifest as difficulty walking, decreased reflexes, or constipation due to autonomic involvement.

🔷 Nurses must assess for gait disturbances, loss of fine motor skills, and report findings promptly.

🔷 Dose adjustment may be required if neuropathy is severe.

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Answer 2

Correct Answers:

Lock the wheels of the bed and the wheelchair.

Rationale :

🔹 Locking the wheels prevents unexpected movement, reducing the risk of falls or injury during the transfer.

🔹 It ensures stability of both the bed and wheelchair, making the transfer safe for both client and nurse.

🔹 This action is part of fall prevention and safe patient handling protocols.

🔹 Positioning aids come after ensuring stability of all equipment.

🔹 Prioritizing safety helps preserve client independence during movement.

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Answer 3

Correct Answers:

"He has an electrical burn. He is stable, and we will update you with any changes."

Rationale :

🔹 This response offers clear, accurate information and reassures the family about the client’s condition.

🔹 It avoids medical jargon and focuses on the current status and plan for communication.

🔹 Upholds the principle of therapeutic communication—concise, honest, and calm.

🔹 It respects the client's privacy and confidentiality while addressing family concern.

🔹 Promotes trust and collaboration with family members.

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Answer 4

Correct Answers:

Bradycardia

Rationale :

🔹 Bradycardia is common in anorexia nervosa due to malnutrition-induced cardiac changes and decreased metabolism.

🔹 It occurs alongside hypothermia, hypotension, and other signs of severe nutritional deficit.

🔹 The body tries to conserve energy in response to chronic starvation.

🔹 Decreased cardiac output is part of the systemic effects of prolonged starvation.

🔹 Continuous monitoring is critical to prevent cardiac complications.

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Answer 5

Correct Answers:

Inspect the mouth for signs of inhalation injuries.

Rationale :

🔹 Airway assessment is the priority in burn clients, especially with facial/chest burns, due to the risk of inhalation injury.

🔹 Airway can rapidly become compromised from edema, requiring intubation.

🔹 Singed nasal hairs, soot in the mouth, or hoarseness may indicate airway damage.

🔹 Assessing early ensures prompt airway management before respiratory distress develops.

🔹 Airway, breathing, circulation (ABC) always guides burn management.

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Answer 6

Correct Answers:

Peanut butter

Rationale :

🟡 Clients with phenylketonuria (PKU) cannot metabolize phenylalanine, an amino acid found in high-protein foods.

🟡 Peanut butter is rich in protein and therefore contains high levels of phenylalanine, which can lead to toxicity.

🟡 During pregnancy, elevated phenylalanine can cause fetal brain damage and congenital defects.

🟡 Dietary restrictions in PKU include avoiding meat, dairy, soy, and nuts, including peanut butter.

🟡 Nutritional counseling is essential to ensure adequate fetal development while maintaining low phenylalanine levels.

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Answer 7

Correct Answers:

Provide a latex-free environment.

Rationale :

🟡 Infants with spina bifida are at high risk of latex allergy due to frequent medical exposure and cross-reactive proteins.

🟡 A latex-free environment reduces the chance of hypersensitivity reactions, including anaphylaxis.

🟡 Common latex-containing items like gloves, catheters, and adhesives should be avoided.

🟡 Creating a safe environment is crucial preoperatively and postoperatively to prevent complications.

🟡 Nurses must be proactive in communicating the allergy risk to the entire care team and family.

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Answer 8

Correct Answers:

Drink 48 to 64 ounces of water daily.

Rationale :

🟡 Clients with preeclampsia are at risk for fluid retention and elevated blood pressure, so maintaining hydration helps with renal perfusion.

🟡 Adequate fluid intake supports placental perfusion and fetal oxygenation.

🟡 Dehydration can worsen symptoms and increase the risk of preterm labor.

🟡 Water helps dilute urine, reducing the chance of urinary tract infections, which can exacerbate complications.

🟡 This volume range ensures a balanced intake without contributing to fluid overload.

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Answer 9

Correct Answers

Blank 1 Correct Option: notify the health care provider
Blank 2 Correct Option: administer pain medications as prescribed

Rationale :

Notify the health care provider

🟡 The client shows signs of worsening urinary obstruction, such as severe pain, restlessness, and distended abdomen.

🟡 Inability to void and rising blood pressure indicates possible renal obstruction or rupture.

🟡 Immediate notification is needed to prevent kidney damage or sepsis.

🟡 Prompt action allows for timely imaging, intervention, or urologic consultation.

🟡 Delaying provider notification could result in irreversible renal complications.

Administer pain medications

🟡 The client reports pain rated 10/10, which requires urgent intervention to reduce distress and sympathetic response.

🟡 Pain management is critical in clients with renal calculi due to intense ureteral spasms.

🟡 Prescribed medications like ketorolac are effective in managing inflammatory pain without compromising renal function.

🟡 Controlling pain also allows for better assessment and cooperation during procedures.

🟡 Adequate analgesia improves quality of care and prevents psychological trauma.

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Answer 10

Correct Answers:

Suction saliva from the client's mouth.

Rationale :

🟡 The priority for an unconscious client is maintaining a patent airway to prevent aspiration.

🟡 Suctioning secretions prevents airway obstruction, which is the highest risk in clients with impaired reflexes.

🟡 Saliva accumulation can lead to aspiration pneumonia, especially after a cerebral hemorrhage.

🟡 Airway maintenance is the first step in the ABCs of emergency care.

🟡 Early intervention reduces the likelihood of hypoxia and further neurological damage.

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QLexNursing

1 :
A nurse is planning care for a preschooler.

Answer Options

2 :
A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take?

3 :
A nurse is caring for a client who has an electrical burn. With the client's permission, the nurse is answering questions from the family about his status. Which of the following responses should the nurse make?

4 :
A nurse is assessing a client who has a new diagnosis of anorexia nervosa. Which of the following findings should the nurse expect?

5 :
A nurse in an emergency room is caring a the client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?

6 :
A nurse is providing teaching to a client who is pregnant and has phenylketonuria (PKU). Which of the following foods should the nurse instruct the client to eliminate from her diet?

7 :
A nurse is planning care for an infant who has spina bifida and is to undergo surgical closure of the myelomeningocele sac? Which of the following interventions should the nurse include in the plan of care?

8 :
A nurse is completing discharge teaching to a client in her 35th week of pregnancy who has mild preeclampsia. Which of the following information about nutrition should be included in the teaching?

9 :
A nurse is caring for an adult client in the emergency department.

Correct Answers

10 :
A nurse is caring for a client who is unconscious following a cerebral hemorrhage. Which of the following nursing interventions is of highest priority?

QLexNursing

1 : A nurse is planning care for a preschooler.

Answer Options

2 : A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take?

3 : A nurse is caring for a client who has an electrical burn. With the client's permission, the nurse is answering questions from the family about his status. Which of the following responses should the nurse make?

4 : A nurse is assessing a client who has a new diagnosis of anorexia nervosa. Which of the following findings should the nurse expect?

5 : A nurse in an emergency room is caring a the client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?

6 : A nurse is providing teaching to a client who is pregnant and has phenylketonuria (PKU). Which of the following foods should the nurse instruct the client to eliminate from her diet?

7 : A nurse is planning care for an infant who has spina bifida and is to undergo surgical closure of the myelomeningocele sac? Which of the following interventions should the nurse include in the plan of care?

8 : A nurse is completing discharge teaching to a client in her 35th week of pregnancy who has mild preeclampsia. Which of the following information about nutrition should be included in the teaching?

9 : A nurse is caring for an adult client in the emergency department.

Correct Answers

10 : A nurse is caring for a client who is unconscious following a cerebral hemorrhage. Which of the following nursing interventions is of highest priority?

1 :
A nurse is planning care for a preschooler.

2 :
A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take?

3 :
A nurse is caring for a client who has an electrical burn. With the client's permission, the nurse is answering questions from the family about his status. Which of the following responses should the nurse make?

4 :
A nurse is assessing a client who has a new diagnosis of anorexia nervosa. Which of the following findings should the nurse expect?

5 :
A nurse in an emergency room is caring a the client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?

6 :
A nurse is providing teaching to a client who is pregnant and has phenylketonuria (PKU). Which of the following foods should the nurse instruct the client to eliminate from her diet?

7 :
A nurse is planning care for an infant who has spina bifida and is to undergo surgical closure of the myelomeningocele sac? Which of the following interventions should the nurse include in the plan of care?

8 :
A nurse is completing discharge teaching to a client in her 35th week of pregnancy who has mild preeclampsia. Which of the following information about nutrition should be included in the teaching?

9 :
A nurse is caring for an adult client in the emergency department.

10 :
A nurse is caring for a client who is unconscious following a cerebral hemorrhage. Which of the following nursing interventions is of highest priority?