A nurse is assessing an adolescent client who has Hodgkin's lymphoma. Which of the following findings should the nurse expect?

Unexplained weight gain

Night sweats

Flushed skin

Decreased body temperature

Answer and Explanation

The Correct Answer is B

A. Unexplained weight gain is not a typical finding in Hodgkin's lymphoma. Weight loss is more commonly associated with this condition.

B. Night sweats are a common symptom of Hodgkin's lymphoma. They can be indicative of the body's response to the cancer.

C. Flushed skin is not typically associated with Hodgkin's lymphoma. Pallor or jaundice may be more commonly observed.

D. Decreased body temperature is not a typical finding in Hodgkin's lymphoma. Infection or fever may lead to an elevated body temperature.

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Correct Answer is C

Explanation

A. A blood pressure of 132/82 mm Hg in an adolescent is within the normal range for their age group. It does not require immediate reporting to the provider.

B. A respiratory rate of 30 breaths per minute in a 3-month-old infant is within the expected (typically 25-40 breaths per minute).

C. A heart rate of 68 beats per minute in an 18-month-old toddler is below the normal range (typically 70-110 beats per minute) and should be reported g to the provider.
D. A rectal body temperature of 37.3° C (99.1° F) in a school-age child is within the normal range (typically 36.5-37.5° C or 97.7-99.5° F). It does not require immediate reporting to the provider.

A. Assist the child into supine position. B. Obtain a throat culture. C. Initiate droplet isolation precautions. D. Check oxygen saturation every 4 hr.

Correct Answer is C

Explanation

A. Assisting the child into a supine position is contraindicated in acute epiglottitis. This can lead to airway obstruction. The child should be allowed to assume a position of comfort, which is typically sitting up and leaning forward.

B. While obtaining a throat culture may be indicated for diagnostic purposes, it is not the first priority in the care of a child with acute epiglottitis. The immediate concern is ensuring airway patency and providing appropriate respiratory support.

C. This is the correct action. Acute epiglottitis is a potentially life-threatening condition that can rapidly lead to airway obstruction. Initiating droplet isolation precautions helps protect healthcare providers and other patients from potential transmission of the causative organism (often Haemophilus influenzae type B).

D. Checking oxygen saturation every 4 hours is important for monitoring respiratory status, but in the case of acute epiglottitis, continuous monitoring of oxygen saturation is often necessary due to the risk of sudden airway obstruction. This action does not address the immediate priority of ensuring a patent airway.

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A nurse is assessing an adolescent client who has Hodgkin's lymphoma. Which of the following findings should the nurse expect?

Nursing Test Bank

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