The parents of a child with acute lymphoblastic leukemia (ALL) are learning to care for their child at home. Which statement made by the parents should the nurse recognize as correct monitoring for early signs of an infection in the child?
Reassess axillary temperature if it is higher than 99.7° F (37.6° C).
Verify if the child has a fever by checking a rectal temperature.
Notify for a temporal temperature greater than 100° F (37.8° C).
Check temperature twice a day with an aural thermometer.
The Correct Answer is C
Choice A reason: Reassessing axillary temperature if it is higher than 99.7° F (37.6° C) is not a correct monitoring for early signs of an infection in the child. Axillary temperature is not the most accurate method of measuring body temperature, especially in children. It can be affected by factors such as clothing, sweating, and room temperature. Axillary temperature is usually lower than the core body temperature by about 1° F (0.6° C). Therefore, a child with an axillary temperature higher than 99.7° F (37.6° C) may already have a significant fever and should be evaluated by a health care provider.
Choice B reason: Verifying if the child has a fever by checking a rectal temperature is not a correct monitoring for early signs of an infection in the child. Rectal temperature is the most accurate method of measuring body temperature, but it is also the most invasive and uncomfortable. It can cause irritation, bleeding, or injury to the rectum, especially in children with low platelet counts or bleeding disorders. Rectal temperature is also not recommended for children with acute lymphoblastic leukemia, as it can increase the risk of introducing bacteria or fungi into the bloodstream.
Choice C reason: Notifying for a temporal temperature greater than 100° F (37.8° C) is a correct monitoring for early signs of an infection in the child. Temporal temperature is a noninvasive and convenient method of measuring body temperature, using an infrared scanner that detects the heat emitted by the temporal artery on the forehead. Temporal temperature is comparable to the core body temperature and can reflect changes in body temperature quickly. A child with acute lymphoblastic leukemia who has a temporal temperature greater than 100° F (37.8° C) may have an infection and should be reported to the health care provider immediately.
Choice D reason: Checking temperature twice a day with an aural thermometer is not a correct monitoring for early signs of an infection in the child. Aural temperature is a noninvasive and easy method of measuring body temperature, using an infrared sensor that detects the heat emitted by the tympanic membrane in the ear. However, aural temperature can be inaccurate or unreliable, as it can be affected by factors such as earwax, ear infections, ear canal shape, and ambient noise. A child with acute lymphoblastic leukemia who has a fever may not be detected by an aural thermometer, and may miss the opportunity for early intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: "Many infants outgrow the need for a shunt after the neonatal period." is not a correct response that the nurse should provide. This statement is false, as most infants with hydrocephalus will need a shunt for life. Only a small percentage of infants with post-hemorrhagic hydrocephalus may outgrow the need for a shunt .
Choice B reason: "The shunt will be replaced as your child grows to reduce pressure in the brain." is the correct response that the nurse should provide. This statement is true, as the shunt will need to be adjusted or replaced as the child grows to accommodate the changes in the size and shape of the head and the amount of fluid drainage. The nurse should educate the mother about the signs and symptoms of shunt malfunction and the need for regular follow-up visits.
Choice C reason: "Other pathways in the brain will drain fluid after the shunt is removed." is not a correct response that the nurse should provide. This statement is false, as the shunt is not removed unless there is a serious complication or the child no longer needs it. The shunt is a permanent device that bypasses the blocked or impaired pathways in the brain and allows the fluid to drain into the abdomen. Without the shunt, the fluid will accumulate in the brain and cause increased pressure and damage.
Choice D reason: "The shunt will have to be reinserted only if an infection or blockage develops." is not a correct response that the nurse should provide. This statement is false, as the shunt is not removed and reinserted unless there is a serious complication or the child no longer needs it. The shunt is a permanent device that stays in place unless it malfunctions or becomes infected. The nurse should educate the mother about the signs and symptoms of shunt infection and the need for prompt treatment.
Correct Answer is D
Explanation
Choice A reason: The ability to crawl is not the most important assessment for the nurse to obtain. Tay-Sachs disease causes progressive loss of motor skills, so the infant may not be able to crawl or may have regressed from crawling. However, this is not a specific sign of the disease and does not indicate the severity of the condition.
Choice B reason: The eyes with cherry-red spot are not the most important assessment for the nurse to obtain. Tay-Sachs disease causes accumulation of gangliosides in the retina, which results in a cherry-red spot in the center of the macula. However, this is not a specific sign of the disease and does not indicate the severity of the condition.
Choice C reason: The difficulty with swallowing is not the most important assessment for the nurse to obtain. Tay-Sachs disease causes muscle weakness and spasticity, which may affect the infant's ability to swallow. However, this is not a specific sign of the disease and does not indicate the severity of the condition.
Choice D reason: The exaggerated startle reaction is the most important assessment for the nurse to obtain. Tay-Sachs disease causes increased sensitivity to sound and touch, which results in an exaggerated startle reaction. This is a specific sign of the disease and indicates the severity of the condition. The exaggerated startle reaction may also trigger seizures, which can be life-threatening. The nurse should monitor the infant's vital signs, seizure activity, and neurological status closely.
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