A nurse is caring for a client who has brain cancer and is undergoing radiation therapy. Which of the following manifestations should the nurse report immediately?

Choice A rationale
The skin assessment reveals bruising and petechiae, which are signs of thrombocytopenia, a condition where the blood has a lower than normal number of platelets. This is significant in a child with leukemia as it may indicate a relapse or bone marrow suppression. The presence of petechiae and unexplained bruising should be reported to the provider as they can be indicative of bleeding disorders or a decrease in platelet count.
Choice B rationale
Oxygen saturation of 92% on room air is below the normal range (95-100%) for a child. This indicates hypoxemia, which can be a sign of respiratory distress or other underlying conditions. Given the child’s history of an upper respiratory infection and leukemia, this finding is critical and should be reported to the provider to ensure appropriate interventions are taken to improve oxygenation.
Choice C rationale
The WBC count is crucial in a child with leukemia. An abnormal WBC count can indicate an infection, relapse, or bone marrow suppression. Monitoring the WBC count helps in assessing the child’s immune status and the effectiveness of the leukemia treatment. Any significant changes in the WBC count should be reported to the provider for further evaluation and management.
Choice D rationale
Subcostal retractions are a sign of increased work of breathing and respiratory distress. This finding, along with the child’s statement of feeling like they can’t breathe, indicates that the child is struggling to maintain adequate ventilation. Reporting this to the provider is essential for timely intervention to prevent further respiratory compromise.
Choice E rationale
An ongoing upper respiratory infection for the last 2 months that has not resolved is concerning, especially in a child with a history of leukemia. This could indicate an underlying immunodeficiency or a more serious infection that requires further investigation and treatment. Reporting this to the provider is necessary to address the persistent infection and prevent complications.
Choice G rationale
The respiratory rate is an important vital sign that can indicate respiratory distress or other underlying conditions. An abnormal respiratory rate, whether too high or too low, can be a sign of respiratory or metabolic issues. Monitoring and reporting the respiratory rate to the provider helps in assessing the child’s respiratory status and determining the need for further intervention.

Choice A rationale
Fever. This statement is incorrect. While fever can occur in clients with ITP due to infections, it is not a specific manifestation of the condition. ITP primarily affects platelet counts and bleeding tendencies.
Choice B rationale
Ecchymosis. This statement is correct. Ecchymosis, or bruising, is a hallmark manifestation of ITP due to low platelet counts and increased bleeding tendencies. Clients with ITP are prone to bruising and bleeding even with minor trauma.
Choice C rationale
Fatigue. This statement is incorrect. While fatigue can occur in clients with ITP due to anemia or chronic illness, it is not a specific manifestation of the condition. ITP primarily affects platelet counts and bleeding tendencies.
Choice D rationale
Elevated WBC. This statement is incorrect. Elevated white blood cell counts are not typically associated with ITP, which primarily affects platelet counts. An elevated WBC may indicate infection or inflammation but is not specific to ITP10111213.