The most recent blood count for a child who has received chemotherapy last week shows neutropenia.
The priority nursing diagnosis for this child is:
Risk for infection.
Risk for hemorrhage.
Altered skin integrity.
Disturbance in body image.
The Correct Answer is A
Choice A rationale
Neutropenia is defined as an abnormally low number of neutrophils, typically an absolute neutrophil count (ANC) below 1,500 cells/mm³ for children, and often < 500 cells/mm³ following chemotherapy. Neutrophils are the primary defense against bacterial and fungal infections. A severely reduced count significantly compromises the child's immune response, making the risk for systemic infection the most immediate and life-threatening priority nursing diagnosis.
Choice B rationale
While chemotherapy can cause thrombocytopenia (low platelet count, normal range 150,000–450,000/mm³), which leads to a risk for hemorrhage, the problem described is specifically neutropenia (low neutrophil count, normal range 1,500–8,000/mm³). Therefore, the priority related to a low white cell count is the risk for overwhelming infection, not necessarily bleeding risk.
Choice C rationale
Chemotherapy can cause stomatitis, dry skin, and mucosal damage, leading to altered skin and mucous membrane integrity, which further increases the risk of infection. However, the direct consequence of neutropenia is a systemic immune deficit, making the risk for infection a broader and higher-priority diagnosis than just local skin breakdown.
Choice D rationale
Changes in physical appearance (like hair loss or weight changes) and the effects of illness can lead to disturbance in body image. This is an important psychosocial nursing diagnosis. However, in Maslow's hierarchy of needs, physiological needs (like preventing life-threatening infection due to neutropenia) must take priority over psychosocial needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1.5"]
Explanation
Step 1 is to convert the ordered dose from grams to milligrams to match the available concentration. 0.5 grams × (1000 milligrams ÷ 1 gram) = 500 milligrams.
Step 2 is to calculate the volume to administer using the available concentration. 500 milligrams ÷ (330 milligrams ÷ 1 milliliter) = 1.51515. milliliters.
Step 3 is to round the calculated volume to the tenths place as required. The nurse will administer 1.5 milliliters.
Correct Answer is C
Explanation
Choice A rationale
Botulinum toxin, commonly known as Botox, is a neurotoxin that is typically injected directly into specific spastic muscles to temporarily block the release of acetylcholine, thereby reducing muscle overactivity and spasticity. It is not an implanted device but an injection, and its effects are localized and temporary.
Choice B rationale
A central venous catheter (CVC) is a line placed into a large vein, typically used for administering medications, fluids, or nutrition, or for drawing blood, especially for long-term or irritating infusions. It has no role in the direct management or control of spasticity associated with cerebral palsy.
Choice C rationale
A baclofen pump is a surgically implanted device that delivers the antispasmodic medication baclofen directly into the intrathecal space surrounding the spinal cord. This localized delivery provides superior spasticity control with lower doses and fewer systemic side effects compared to oral baclofen, and it is a common treatment for severe spasticity.
Choice D rationale
A vagal nerve stimulator (VNS) is an implanted device used primarily as an adjunctive therapy to control partial-onset seizures or treat certain forms of depression. It works by sending electrical impulses to the brain via the vagus nerve in the neck. It is not indicated for the management of spasticity in cerebral palsy.
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