A nurse is caring for a child with newly diagnosed acute lymphoblastic leukemia. What clinical findings does the nurse anticipate when assessing the child? Select all that apply.

Fatigue

Generalized edema

Pallor

Jaundice

Multiple bruises

Answer and Explanation

Correct Answer : A,C,E

A. Fatigue: Children with ALL often experience fatigue and weakness due to decreased red blood cell and platelet production as a result of bone marrow involvement by leukemia cells.

C. Pallor: Pallor, or paleness, is a common finding in children with ALL because of anemia (reduced red blood cell count).

E. Multiple bruises: Children with ALL may have an increased tendency to bruise and bleed due to low platelet counts, making them susceptible to easy bruising and petechiae.

The other options, B (Generalized edema) and D (Jaundice), are not typical clinical findings associated with ALL. Generalized edema is not a common symptom, and jaundice (yellowing of the skin and eyes) is more commonly associated with liver conditions, not leukemia.

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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.

A. Altered level of consciousness and treaty pulse B. Bounding pulses and mottled skin C. Capillary refill of 2 seconds and blood pressure of 96/47 mmHg D. Extremities warm to the touch and pale skin

Correct Answer is A

Explanation

A.Altered level of consciousness and thready pulse.

In a child after heart surgery to correct Tetralogy of Fallot (TOF), a thready pulse and altered level of consciousness can be indicative of poor cardiac output. This may suggest that the heart is not effectively pumping blood to meet the body's needs.

B. Bounding pulses and mottled skin: Bounding pulses and mottled skin are not typical signs of decreased cardiac output. Bounding pulses are often associated with increased cardiac output.

C. Capillary refill of 2 seconds and blood pressure of 96/47 mmHg: A capillary refill of 2 seconds is within the normal range, and a blood pressure of 96/47 mmHg is reasonable for a child. These findings do not necessarily indicate poor cardiac output.

D. Extremities warm to the touch and pale skin: Warm extremities and pale skin are not typical signs of decreased cardiac output. Cold extremities and cyanosis may be more concerning signs.

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A nurse is caring for a child with newly diagnosed acute lymphoblastic leukemia. What clinical findings does the nurse anticipate when assessing the child? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

When assessing a child after heart surgery to correct Tetralogy of Fallot (TOP) which finding should alert the nurse to suspect a le carat output?

Correct Answer is A

Explanation

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