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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: The lumen of the aorta reduces the volume of blood flow to the lower extremities is the correct pathophysiologic mechanism that supports the findings. This is because coarctation of the aorta is a congenital condition that causes a narrowing of the aorta, usually near the ductus arteriosus. This results in increased resistance to blood flow from the heart to the lower body, leading to higher blood pressure and stronger pulses in the upper extremities and lower blood pressure and weaker pulses in the lower extremities.
Choice B reason: The aortic semilunar valve obstructs blood flow into the systemic circulation is not the correct pathophysiologic mechanism that supports the findings. This is because the aortic semilunar valve is located at the base of the aorta and prevents blood from flowing back into the left ventricle. If the valve is obstructed, it would cause aortic stenosis, which is a different condition from coarctation of the aorta. Aortic stenosis would cause symptoms such as chest pain, shortness of breath, and fainting.
Choice C reason: The pulmonic valve prevents adequate blood volume into the pulmonary circulation is not the correct pathophysiologic mechanism that supports the findings. This is because the pulmonic valve is located at the base of the pulmonary artery and prevents blood from flowing back into the right ventricle. If the valve is obstructed, it would cause pulmonic stenosis, which is a different condition from coarctation of the aorta. Pulmonic stenosis would cause symptoms such as cyanosis, fatigue, and heart murmur.
Choice D reason: An opening in the atrial septum causes a murmur due to a turbulent left to right shunt is not the correct pathophysiologic mechanism that supports the findings. This is because an opening in the atrial septum is a defect in the wall that separates the two upper chambers of the heart. It would cause a condition called atrial septal defect, which is different from coarctation of the aorta. Atrial septal defect would cause symptoms such as difficulty breathing, frequent respiratory infections, and heart palpitations.
Correct Answer is B
Explanation
Choice A reason: Assessing for presence of a supernumerary breast nipple is not a relevant technique to determine if the client has reached the age of menarche. A supernumerary breast nipple is an extra nipple that develops along the embryonic milk line, usually in the chest or abdomen. It is a congenital anomaly that affects about 1% to 5% of the population, and it has no relation to the onset of menstruation.
Choice B reason: Using the Tanner staging to determine sexual maturity is a valid technique to determine if the client has reached the age of menarche. The Tanner staging is a scale that assesses the development of secondary sexual characteristics, such as breast growth, pubic hair growth, and genital development, in relation to the chronological age of the child. The Tanner staging can help estimate the stage of puberty and the likelihood of menarche, which usually occurs around Tanner stage 3 or 4 in girls.
Choice C reason: Palpating for evidence of temporary gynecomastia is not an appropriate technique to determine if the client has reached the age of menarche. Gynecomastia is the enlargement of breast tissue in males, due to hormonal imbalance, medication side effects, or other causes. It is a common condition that affects up to 70% of adolescent boys, and it usually resolves spontaneously within a few months or years. Gynecomastia has no relevance to the onset of menstruation in girls.
Choice D reason: Calculating approximate age menstruation should occur is not a reliable technique to determine if the client has reached the age of menarche. The age of menarche varies widely among individuals, depending on genetic, environmental, nutritional, and psychosocial factors. The average age of menarche in the United States is about 12.5 years, but it can range from 8 to 16 years. Therefore, calculating the approximate age of menarche based on averages or norms may not reflect the actual situation of the client.
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