Nursing care of a child who is immunosuppressed due to leukemia or chemotherapeutic agents should include:
(choose one best answer)
Have them share a room with a child with active mumps
Restrict oral fluids
Strict isolation
Use good handwashing
The Correct Answer is D
Choice A reason: This choice is incorrect because having them share a room with a child with active mumps may expose them to infection and worsen their condition. A child who is immunosuppressed due to leukemia or chemotherapeutic agents has a weakened immune system and is more susceptible to infections from bacteria, viruses, fungi, or parasites. Therefore, they should be placed in a private room or cohorted with another immunosuppressed child.
Choice B reason: This choice is incorrect because restricting oral fluids may cause dehydration and electrolyte imbalance in the child who is immunosuppressed due to leukemia or chemotherapeutic agents. A child who is immunosuppressed due to leukemia or chemotherapeutic agents may have increased fluid losses from vomiting, diarrhea, fever, or sweating. Therefore, they should be encouraged to drink adequate fluids to maintain hydration and electrolyte balance.
Choice C reason: This choice is incorrect because strict isolation may cause psychological distress and social isolation in the child who is immunosuppressed due to leukemia or chemotherapeutic agents. A child who is immunosuppressed due to leukemia or chemotherapeutic agents may benefit from protective isolation, which involves using standard precautions and additional measures such as wearing gloves, gowns, masks, or eye protection when in contact with the child or their body fluids. However, strict isolation, which involves limiting visitors and activities, may harm the child's emotional and developmental well-being.
Choice D reason: This choice is correct because using good handwashing is essential nursing care for a child who is immunosuppressed due to leukemia or chemotherapeutic agents. Handwashing is the most effective way to prevent the transmission of microorganisms that can cause infections. The nurse should wash their hands before and after touching the child or their belongings, and teach the child and their family members to do the same. The nurse should also use alcohol-based hand rubs when water and soap are not available.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This choice is incorrect because constructing a model airplane is not an appropriate activity for a 4- year-old child who requires airborne precautions. Airborne precautions are infection control measures that prevent the transmission of microorganisms that can be spread by small droplets that remain suspended in the air, such as tuberculosis, measles, or chickenpox. They involve placing the child in a negative-pressure room with a HEPA filter, wearing a respirator mask, and limiting movement outside the room. Constructing a model airplane may involve small parts that can be choking hazards, sharp edges that can cause injury or glue that can cause irritation or allergy. Therefore, this activity may not be safe or suitable for the child.
Choice B reason: This choice is incorrect because pulling a wagon with toys in the hallway is not an appropriate activity for a 4-year-old child who requires airborne precautions. As explained above, airborne precautions involve limiting movement outside the room to prevent exposure and transmission of microorganisms. Pulling a wagon with toys in the hallway may violate these precautions and increase the risk of infection for the child and others.
Therefore, this activity may not be allowed or advisable for the child.
Choice C reason: This choice is correct because putting a large-piece puzzle together is an appropriate activity for a 4-year-old child who requires airborne precautions. Putting a large-piece puzzle together can help to stimulate the child's cognitive, visual, and fine motor skills by requiring them to match shapes, colors, and patterns. It can also help to reduce boredom, frustration, or anxiety by providing entertainment, diversion, or achievement. Therefore, this activity may be beneficial and enjoyable for the child.
Choice D reason: This choice is incorrect because watching a video game in the playroom is not an appropriate activity for a 4-year-old child who requires airborne precautions. As explained above, airborne precautions involve limiting movement outside the room to prevent exposure and transmission of microorganisms. Watching a video game in the playroom may violate these precautions and increase the risk of infection for the child and others.
Therefore, this activity may not be permitted or recommended for the child.
Correct Answer is D
Explanation
Choice A: Using a pain-rating tool to determine the severity of the joint pain is not the priority assessment for an 8-year-old child who has acute rheumatic fever, which is an inflammatory condition that can affect various organs, especially the heart, joints, skin, and brain. Joint pain is one of the major criteria for diagnosing acute rheumatic fever and can affect one or more large joints, such as knees, ankles, elbows, or wrists. Joint pain can be managed with analgesics or anti-inflammatory drugs.
Choice B: Assessing the client's erythematous rash is not the priority assessment for an 8-year-old child who has acute rheumatic fever, which is an inflammatory condition that can affect various organs, especially the heart, joints, skin, and brain. The erythematous rash is one of the minor criteria for diagnosing acute rheumatic fever and can appear as pink or red patches on the trunk or limbs. The erythematous rash can fade or change location over time and does not require any specific treatment.
Choice C: Identifying the degree of parental anxiety related to the diagnosis is not the priority assessment for an 8-year-old child who has acute rheumatic fever, which is an inflammatory condition that can affect various organs, especially the heart, joints, skin, and brain. Parental anxiety related to the diagnosis can affect their coping skills and ability to care for their child. Parental anxiety can be addressed by providing education, support, and referral to appropriate resources.
Choice D: Auscultating the rate and regularity of the child's heart sounds and notifying the provider immediately of abnormalities is the priority assessment for an 8-year-old child who has acute rheumatic fever, as it can indicate cardiac involvement, which is the most serious complication of acute rheumatic fever. Cardiac involvement can cause damage to the heart valves, myocardium, or pericardium and lead to heart failure or death. Abnormalities in heart sounds may include murmurs, rubs, gallops, or arrhythmias.
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