A nurse is planning care for a preschooler who has neutropenia. Which of the following interventions should the nurse include in the plan?
Avoid raw fruits and vegetables in the child's diet.
Administer vaccines prior to discharge.
Obtain the child's rectal temperature once daily.
Bathe the child every other day.
The Correct Answer is A
Choice A reason: Avoiding raw fruits and vegetables is crucial for a child with neutropenia because these foods can harbor bacteria that may cause infection in a child with a weakened immune system. It is important to minimize the risk of infection by providing a diet that includes cooked or thoroughly washed fruits and vegetables.
Choice B reason: Administering vaccines prior to discharge may not be appropriate for a child with neutropenia, as live vaccines are contraindicated due to the risk of infection. Vaccination should be deferred until the child's immune system has recovered.
Choice C reason: Obtaining the child's rectal temperature once daily is not recommended for a child with neutropenia due to the risk of introducing bacteria into the body, which can lead to infection.
Choice D reason: Bathing the child every other day does not directly relate to the care of neutropenia. While personal hygiene is important, the frequency of bathing should be based on the child's needs and condition.
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Related Questions
Correct Answer is B
Explanation
Choice A reason: Constipation is not typically associated with nephrotic syndrome. It may be related to dietary factors, dehydration, or other gastrointestinal issues.
Choice B reason: Increased abdominal girth can be an indication of nephrotic syndrome due to the accumulation of fluid in the abdomen (ascites) as a result of low albumin levels in the blood, which is a characteristic of this condition.
Choice C reason: Irritability can be a non-specific symptom and may be caused by a variety of factors. It is not a direct indication of nephrotic syndrome.
Choice D reason: Increased urinary output is not characteristic of nephrotic syndrome. In fact, decreased urine output may be observed due to the loss of protein in the urine and subsequent fluid retention in the body.
Correct Answer is A
Explanation
Choice A reason: Irregular bluish pigmentation on the sacral area could indicate a Mongolian spot, which is common and usually harmless, but it could also suggest other conditions that may require further evaluation. Reporting this finding is important for proper assessment and documentation.
Choice B reason: Slow, rhythmic movements of the lower extremities are normal in newborns and are known as primitive reflexes. These movements are expected and do not typically require reporting unless they are absent or abnormal.
Choice C reason: An anterior fontanel size of 3 cm (1.2 in) is within the normal range for a newborn. The fontanel should be soft and flat, and changes in size or tension should be monitored over time.
Choice D reason: Enlarged breasts in newborns are also common due to maternal hormones and usually resolve without intervention. It is not a finding that typically requires immediate reporting unless there is redness, swelling, or discharge.
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