A nurse is caring for a preschooler who has a brain tumor. Which of the following findings is the priority for the nurse to report to the provider?
Nightmares
Hyperactivity
Pruritus
Diplopia
The Correct Answer is D
A. Nightmares are common in children and may not be directly related to the brain tumor. While they should be addressed, they are not the priority in this case.
B. Hyperactivity can be a normal behavior in preschoolers. It may or may not be related to the brain tumor. Other symptoms should take precedence.
C. Pruritus (itching) is a common symptom that can have various causes, and it may not be directly related to the brain tumor. It should be addressed but is not the priority in this case.
D. Correct. Diplopia (double vision) can be a neurological symptom associated with increased
intracranial pressure or other complications related to a brain tumor. It is important to report this finding promptly to the provider for further evaluation and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Starting the IV in the infant's foot is not the preferred site for a 12-month-old who is ambulatory or beginning to walk, as it can interfere with mobility. The hand, forearm, or scalp (if necessary) are preferred sites.
B. Using a 24-gauge catheter is the correct choice, as smaller-gauge catheters (24- to 26-gauge) are appropriate for infants to minimize trauma and facilitate proper IV access.
C. Changing the IV site every 3 days is a general guideline for adults, but in infants, the site should be assessed frequently and changed as needed based on signs of infiltration or complications.
D. Covering the insertion site with an opaque dressing is incorrect because a transparent dressing is preferred to allow for continuous assessment of the site for complications such as infiltration or phlebitis.
Correct Answer is D
Explanation
A. WBC count 15,000/mm3 is elevated, which may indicate ongoing leukemia activity. It does not necessarily indicate a therapeutic effect.
B. RBC count 5/mm3 is extremely low and indicates severe anemia. This finding suggests that the treatment may not be having the desired therapeutic effect.
C. Hemoglobin 6.8 g/dL is very low and indicates severe anemia. This is a concerning finding and suggests that the treatment may not be effective.
D. This is the correct answer. A platelet count of 98,000/mm3 is within a range that is generally considered acceptable for a child receiving treatment for leukemia. While it is lower than normal, it is not severely low and suggests that the treatment may be having a therapeutic effect.
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