A nurse is caring for a toddler who received radiation therapy 2 years ago for a brain tumor. Which of the following should the nurse identify as a late adverse effect of the radiation therapy?
Desquamation
Nausea
Mucosal ulceration
Short stature
The Correct Answer is D
A. Desquamation: Skin peeling or desquamation is an acute side effect of radiation therapy, typically appearing during or shortly after treatment, not years later.
B. Nausea: Nausea is also an acute effect that commonly occurs during radiation therapy, especially when the gastrointestinal tract or brain is involved. It is not considered a late effect years after treatment.
C. Mucosal ulceration: Ulceration of the mucous membranes is an early complication related to radiation affecting rapidly dividing cells. It resolves after treatment and is not a late manifestation.
D. Short stature: Radiation therapy in young children can damage growth plates and affect hormone production, leading to growth delays and short stature. This is a recognized late adverse effect seen years after treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Respiratory rate: A respiratory rate of 22/min is within the normal range for a school-age child (18–30/min). This does not suggest acute distress or worsening dehydration, so it does not require reporting.
B. Heart rate: A heart rate of 96/min is normal for a school-age child (75–118/min). It does not indicate tachycardia or hypovolemic compromise and therefore is not concerning.
C. Capillary refill: A prolonged capillary refill time is a key indicator of poor peripheral perfusion, which can be a sign of moderate to severe dehydration and hypovolemia. This finding suggests that the child is not adequately compensating for their fluid loss.
D. Urine output: A urine output of 100 mL in 4 hours is within the expected range for a child of this weight. The normal urine output for a child is approximately 1 mL/kg/hr. For this child (22.7 kg), the expected output would be 22.7 mL/hr. Over 4 hours, this would be 90.8 mL.
Correct Answer is C
Explanation
A. Place the child in a mummy restraint: A mummy restraint is typically used for short procedures, such as IV insertions or blood draws. It is not appropriate for continuous use after surgery, as it can restrict movement excessively and cause distress.
B. Swaddle the toddler in a blanket: Swaddling may be effective for infants, but toddlers are too mobile and strong to be safely contained in a blanket. It would not reliably prevent the child from touching the surgical site.
C. Place the toddler in bilateral elbow restraints: Elbow restraints prevent the toddler from bending their arms and reaching the incision site while still allowing mobility of the hands and legs. This method is commonly prescribed after cleft lip and palate repair to protect the surgical area.
D. Obtain a prescription for lorazepam: Sedation is not routinely used to prevent a child from touching surgical sites, as it carries unnecessary risks. Non-pharmacological measures like restraints are safer and more effective for protecting the incision.
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