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

Answer and Explanation

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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Correct Answer is A

Explanation

Choice A reason: This choice is correct because examining the child's tympanic membrane at the end of the physical examination is the best strategy to avoid upsetting or frightening the child. The tympanic membrane is the thin membrane that separates the outer ear from the middle ear, and it can be examined by using an otoscope, which is a device that has a light and a magnifying lens. Examining the tympanic membrane may be uncomfortable or painful for the child, especially if they have an ear infection or inﬂammation. Therefore, performing this procedure at the end of the examination can help to minimize the child's distress and resistance.

Choice B reason: This choice is incorrect because examining the child's tympanic membrane before auscultating the chest and abdomen is not a good strategy to avoid upsetting or frightening the child. Auscultating the chest and abdomen is a procedure that involves listening to the sounds of the heart, lungs, and bowel by using a stethoscope, which is a device that has a chest piece and earpieces. Auscultating the chest and abdomen may be soothing or relaxing for the child, as it does not cause any discomfort or pain. Therefore, performing this procedure before examining the tympanic membrane can help to calm and distract the child.

Choice C reason: This choice is incorrect because examining the child's tympanic membrane at the beginning of the physical examination is not a good strategy to avoid upsetting or frightening the child. Examining the tympanic membrane at the beginning of the examination may cause anxiety or fear in the child, which can affect their cooperation and trust for the rest of the examination. Therefore, performing this procedure at the beginning of the examination can increase the child's distress and resistance.

Choice D reason: This choice is incorrect because examining the child's tympanic membrane before examining the
head and neck is not a good strategy to avoid upsetting or frightening the child. Examining the head and neck is a procedure that involves inspecting and palpating the scalp, hair, face, eyes, ears, nose, mouth, throat, lymph nodes, and thyroid gland. Examining the head and neck may be easy or pleasant for the child, as it does not cause any discomfort or pain. Therefore, performing this procedure before examining the tympanic membrane can help to establish rapport and confidence with the child.

A. Reduce environmental stimuli. B. Document intake and output. C. Administer antibiotics when available. D. Maintain seizure precautions.

Correct Answer is C

Explanation

Choice A: Reducing environmental stimuli can help decrease the discomfort and agitation of a child who has meningitis, as they may experience headache, photophobia, and neck stiﬀness. However, this action is not the priority, as it does not address the cause of the infection or prevent complications.

Choice B: Documenting intake and output can help monitor the ﬂuid balance and hydration status of a child who has meningitis, as they may have fever, vomiting, and decreased oral intake. However, this action is not the priority, as it does not address the cause of the infection or prevent complications.

Choice C: Administering antibiotics when available can help treat the bacterial infection that causes meningitis and prevent serious complications such as brain damage, hearing loss, or death. This action is the priority, as it can save the child's life and improve their outcome.

Choice D: Maintaining seizure precautions can help protect the child from injury and provide safety measures in case of a seizure, as meningitis can cause increased intracranial pressure and seizures. However, this action is not the priority, as it does not address the cause of the infection or prevent complications.

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Nursing care of a child who is immunosuppressed due to leukemia or chemotherapeutic agents should include: (choose one best answer)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a toddler at a well-child visit. At what point in the physical examination should the nurse examine the child's tympanic membrane? (The child will likely view this as invasive and traumatic)

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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Nursing care of a child who is immunosuppressed due to leukemia or chemotherapeutic agents should include:

(choose one best answer)