A pediatric nurse is assisting with the care of a school-age child who has leukemia.
Blood pressure
Skin assessment
Breath sounds
Oxygen saturation
WBC count
Retractions
Respiratory rate
Hemoglobin
Correct Answer : B,C,D,F,G
A. Blood pressure: The blood pressure is within normal limits and does not indicate an acute issue in this context.
B. Skin assessment: The presence of pallor and bruising indicates potential anemia and thrombocytopenia, common in leukemia patients but concerning signs that need to be monitored.
C. Breath sounds: Rhonchi in the upper lobes suggest respiratory congestion or infection, which is dangerous in an immunocompromised child.
D. Oxygen saturation: A drop in oxygen saturation to 90% indicates impaired oxygenation, which could signify respiratory distress or worsening infection.
E. WBC count: Although WBC count is within the low-normal range, it does not independently indicate an immediate change in the child’s condition.
F. Retractions: Subcostal retractions indicate respiratory distress, which is critical to report as it could escalate quickly in a child.
G. Respiratory rate: The increased respiratory rate (from 22 to 30/min) reflects respiratory distress and may worsen if the infection progresses.
H. Hemoglobin: While low, the hemoglobin is not acutely life-threatening in this case and would not necessarily prompt urgent intervention without other symptoms.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Ineffective airway clearance related to swelling of the lymph nodes: Multiple myeloma primarily affects bone marrow and bones rather than lymph nodes, so this diagnosis is less relevant.
B. Ineffective tissue perfusion related to vascular occlusion: Vascular occlusion is not a common complication of multiple myeloma, although hyperviscosity can occur, especially in advanced stages. However, the primary concern is bone integrity.
C. Risk for injury related to compromised bone integrity: Multiple myeloma weakens bones due to the presence of osteolytic lesions, increasing the risk for fractures. Teaching the family about measures to prevent injury is crucial.
D. Risk for deficit fluid volume related to a bleeding disorder: Multiple myeloma does not usually cause a primary bleeding disorder that would result in fluid volume deficit. Bone fractures and hypercalcemia are more immediate concerns.
Correct Answer is D
Explanation
A. RBC's: Red blood cells (RBCs) are not indicative of Hodgkin’s lymphoma; they are involved in oxygen transport throughout the body and are not a specific marker for any lymphoma.
B. Bence-Jones Cells: Bence-Jones proteins are light chain proteins found in the urine of patients with multiple myeloma, not Hodgkin’s lymphoma.
C. Stem Cells: Stem cells are progenitor cells that can develop into various blood cell types but are not characteristic of Hodgkin’s lymphoma specifically. Reed-Sternberg cells, not stem cells, are the hallmark of this disease.
D. Reed-Sternberg Cell: Reed-Sternberg cells are large, abnormal B cells that are characteristic of Hodgkin’s lymphoma. Their presence in lymph node tissue is a key diagnostic feature of the disease.
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