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 C
Explanation
Choice A rationale
A child with a diagnosed latex sensitivity, especially one with a history of myelomeningocele which carries a high risk, should absolutely wear medical alert identification. This ensures that emergency medical personnel and others are immediately aware of the allergy to prevent exposure to potentially life-threatening latex products.
Choice B rationale
It is crucial to inform all caregivers, including school nurses, teachers, and daycare providers, about the child's latex allergy. This allows them to implement proper avoidance strategies in their respective environments and recognize early signs of a reaction, ensuring the child's safety outside the home.
Choice C rationale
The statement that a product's label always indicates whether it is latex-free is incorrect and indicates a need for further teaching. Many items contain "hidden" latex, and labeling may not be mandatory or always comprehensive, requiring parents to exercise extreme caution and directly inquire about product composition.
Choice D rationale
Complete avoidance of all contact with products containing natural rubber latex is the only definitive way to prevent an allergic reaction in a sensitized child. Exposure, even to airborne particles from latex-containing materials, can trigger reactions ranging from mild skin irritation to severe anaphylaxis.
Correct Answer is ["A","B","E"]
Explanation
Choice A rationale
A stiff neck, or nuchal rigidity, is a classic sign of meningeal irritation, which is characteristic of meningitis, especially the bacterial form. The stiffness and pain occur because inflammation of the meninges surrounding the brain and spinal cord causes muscle spasm when the neck is passively flexed, significantly restricting the range of motion.
Choice B rationale
Photophobia, an extreme sensitivity to light, is caused by the irritation and inflammation of the meninges, particularly those surrounding the optic nerve roots. This symptom is a common indicator of increased intracranial pressure and meningeal inflammation associated with bacterial meningitis, signaling a severe central nervous system infection.
Choice C rationale
Headache is one of the most common and prominent symptoms of meningitis, resulting from the combination of meningeal inflammation, increased intracranial pressure, and cerebral edema. Therefore, the absence of a headache would be an atypical finding, making its presence, not absence, a finding that supports the suspicion of bacterial meningitis.
Choice D rationale
A positive Brudzinski sign, which is the involuntary flexion of the hips and knees when the patient's neck is passively flexed, is a classic sign of meningeal irritation. A negative Brudzinski sign indicates the absence of this specific sign of meningeal irritation, suggesting a lower likelihood of meningitis, though its absence does not rule out the disease.
Choice E rationale
Vomiting, often projectile and without preceding nausea, is a common symptom in both children and adolescents with bacterial meningitis. This symptom is typically a direct consequence of the sudden increase in intracranial pressure caused by the inflammation and edema within the central nervous system, irritating the vomiting center in the brainstem.
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