A nurse is admitting a child who has leukemia and a critically low platelet count. Which of the following precautions should the nurse initiate?
Neutropenic
Droplet
Bleeding
Contact
The Correct Answer is C
A. Neutropenic Precautions: Neutropenia refers to a low neutrophil count, a type of white blood cell responsible for fighting infections. While children with leukemia are at risk for neutropenia due to the disease and its treatment, the primary concern in this scenario is the critically low platelet count and the risk of bleeding. Neutropenic precautions focus on preventing infections.
B. Droplet Precautions: Droplet precautions are used when dealing with respiratory infections that are transmitted through respiratory droplets, such as coughing or sneezing. This is not the primary concern for a child with leukemia and a low platelet count, as the main risk is bleeding due to the low platelet count.
C. Bleeding Precautions: Leukemia, especially in a child with a critically low platelet count, puts the child at a high risk of bleeding. Platelets are essential for blood clotting, and when they are severely decreased, even minor injuries can lead to excessive bleeding. The nurse should take precautions to minimize the risk of bleeding. This includes avoiding invasive procedures, using a soft toothbrush, and ensuring that the child does not participate in activities that could result in injury.
D. Contact Precautions: Contact precautions are used to prevent the transmission of infectious diseases through direct contact. While a child with leukemia may have a weakened immune system and be at risk of infections, the primary concern in this case is the critically low platelet count and the risk of bleeding. Contact precautions are more relevant in cases of contagious diseases where physical contact could transmit the infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Increased pulse rate.
Iron deficiency anemia can lead to a reduced oxygen-carrying capacity in the blood. As a compensatory mechanism, the heart may pump faster to deliver more oxygen to tissues. This can result in an increased pulse rate. Children with iron deficiency anemia may also experience weakness, fatigue, and pallor.
B. Increased blood pressure is not a common symptom of iron deficiency anemia. In fact, iron deficiency anemia can often lead to lower blood pressure due to the reduced oxygen-carrying capacity of the blood.
C. Warm skin is not a typical symptom of iron deficiency anemia. Skin temperature may not be directly affected by this condition.
D. Cyanosis of the nail beds is not a symptom of iron deficiency anemia. Cyanosis refers to bluish discoloration of the skin or mucous membranes due to reduced oxygen levels in the blood, which is more commonly associated with respiratory or cardiovascular issues. Iron deficiency anemia primarily affects the oxygen-carrying capacity of the blood but does not lead to cyanosis.
Correct Answer is D
Explanation
A.Pyloric stenosis is a condition where there's narrowing of the opening between the stomach and the small intestine. It is not related to inadequate motility of the intestine.
B.Enterocolitis refers to inflammation of the small intestine and colon. While this can cause obstruction in some cases, it's not the primary cause of inadequate motility as seen in the question.
C.Encopresis is the voluntary or involuntary passage of feces outside the toilet in children who should be toilet trained. It is not a cause of mechanical intestinal obstruction.
D. Hirschsprung's disease is a congenital disorder where there is inadequate motility in part of the intestine, leading to mechanical obstruction. It usually affects the colon and is due to the absence of ganglion cells in the affected segment of the bowel.
So, Hirschsprung's disease is the specific condition that leads to inadequate motility and mechanical obstruction of part of the intestine in infants.
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