The most recent blood count for a child who received chemotherapy last week shows neutropenia. What is the priority nursing diagnosis for this child?
Disturbance in body image
Altered skin integrity
Risk for hemorrhage
Risk for infection
The Correct Answer is D
A. Disturbance in body image: This may be relevant due to hair loss or other changes, but not a priority in neutropenia.
B. Altered skin integrity: Important if skin breakdown exists, but infection prevention takes precedence in neutropenic patients.
C. Risk for hemorrhage: A low platelet count would prompt this diagnosis, not neutropenia.
D. Risk for infection: Neutropenia (low neutrophil count) severely compromises immunity, making the client highly susceptible to life-threatening infections.
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Related Questions
Correct Answer is D
Explanation
A. "Your mom will know more about that than I do." Dismisses the child’s existential concern and deflects the conversation.
B. "Why are you asking me that?" This may sound confrontational and may discourage further emotional expression.
C. "Your grandparents and God will take care of you." Although comforting, it assumes the child’s spiritual beliefs and does not explore the child’s feelings.
D. "Who do you think will take care of you?" This is an open-ended, therapeutic response that encourages the child to express their own thoughts, fears, and beliefs about death and the afterlife.
Correct Answer is B
Explanation
A. "I do not plan to offer my baby a pacifier during naps or at bedtime.": Pacifier use during sleep is associated with a reduced risk of SIDS. Not offering it may increase risk.
B. "My baby will be placed on her back when sleeping.": Placing infants on their backs to sleep is the safest position and is strongly recommended to prevent SIDS.
C. "Our baby will sleep in my bed because I am breastfeeding.": Bed-sharing increases the risk of SIDS due to potential suffocation or overlay; room-sharing without bed-sharing is recommended.
D. "We will place an antique quilt in our baby's crib.": Soft bedding, including quilts, increases the risk of suffocation and SIDS. The crib should have a firm mattress with a fitted sheet only.
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