A nurse on an oncology unit is assessing a child who has a brain tumor. Which of the following findings should the nurse expect?
Increased appetite
Negative Babinski reflex
Tachycardia
Hyporeflexia
The Correct Answer is D
Choice A reason: Increased appetite is not a common finding in children with brain tumors. On the contrary, they may have decreased appetite, nausea, vomiting, or weight loss due to increased intracranial pressure or tumor location.
Choice B reason: Negative Babinski reflex is a normal finding in children over 2 years old and adults. It means that the toes curl downward when the sole of the foot is stimulated. A positive Babinski reflex, which means that the big toe moves upward and the other toes fan outward, is a sign of damage to the corticospinal tract, which may be caused by a brain tumor.
Choice C reason: Tachycardia, or rapid heart rate, is not a specific finding for brain tumors. It may be caused by many factors, such as fever, pain, anxiety, dehydration, or medications. However, some brain tumors may affect the autonomic nervous system, which regulates the heart rate, and cause bradycardia, or slow heart rate.
Choice D reason: Hyporeflexia, or diminished reflexes, is a possible finding in children with brain tumors. It indicates a dysfunction of the lower motor neurons, which may be affected by the tumor or the increased intracranial pressure. Hyporeflexia may manifest as weakness, numbness, or decreased muscle tone in the affected limbs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Assessing the client's erythematous rash is an important action for the nurse to take, but it is not the priority. The rash is one of the minor criteria for diagnosing acute rheumatic fever, and it may not be present in all cases. The rash is usually non-pruritic and migratory, and it appears on the trunk and extremities.
Choice B reason: Identifying the degree of parental anxiety related to the diagnosis is an appropriate action for the nurse to take, but it is not the priority. The nurse should provide emotional support and education to the parents, and address their concerns and questions. However, this is not the most urgent action.
Choice C reason: Auscultating the rate and characteristics of the child's heart sounds is the priority action for the nurse to take, as it can detect the presence and severity of carditis, which is the most serious complication of acute rheumatic fever. Carditis is the inflammation of the heart muscle, valves, or pericardium, and it can cause murmurs, tachycardia, dysrhythmias, heart failure, or death.
Choice D reason: Using a pain-rating tool to determine the severity of the joint pain is an important action for the nurse to take, but it is not the priority. The joint pain is one of the major criteria for diagnosing acute rheumatic fever, and it is usually severe and migratory, affecting the large joints such as the knees, ankles, elbows, or wrists. The nurse should assess the pain level and provide analgesics and anti-inflammatory medications as prescribed.
Correct Answer is B
Explanation
Choice A reason: Gastrointestinal system is not the primary system affected by Kawasaki disease, although some children may have symptoms such as diarrhea, vomiting, or abdominal pain. These are not specific to Kawasaki disease and may be caused by other conditions.
Choice B reason: Cardiovascular system is the most important system to monitor in children with Kawasaki disease, as it can cause inflammation of the blood vessels, especially the coronary arteries that supply the heart. This can lead to serious complications such as coronary artery aneurysms, myocarditis, pericarditis, valvular dysfunction, and arrhythmias. Children with Kawasaki disease need regular echocardiograms to assess the cardiac function and structure.
Choice C reason: Respiratory system is not the primary system affected by Kawasaki disease, although some children may have symptoms such as cough, rhinorrhea, or wheezing. These are not specific to Kawasaki disease and may be caused by other conditions.
Choice D reason: Integumentary system is not the primary system affected by Kawasaki disease, although some children may have symptoms such as rash, peeling of the skin, red eyes, red lips, and red tongue. These are not specific to Kawasaki disease and may be caused by other conditions.
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