The nurse is caring for a 9-year-old undergoing chemotherapy to treat leukemia. Select the priority nursing goal for the child's plan of care.
Encourage intake of favorite foods to increase weight and promote normal growth.
Utilize approaches to minimize risk of infection and bleeding episodes.
Provide age-appropriate activities to promote optimum cognitive and motor skills development.
Provide emotional support for the child and family members that relieve stress.
The Correct Answer is B
Choice A reason: Encouraging intake of favorite foods to increase weight and promote normal growth is an important nursing goal for a child with leukemia, but it is not the priority. Chemotherapy can cause nausea, vomiting, and loss of appetite, which can affect the child's nutritional status and growth. However, these effects can be managed with antiemetics, supplements, and small frequent meals.
Choice B reason: Utilizing approaches to minimize risk of infection and bleeding episodes is the priority nursing goal for a child with leukemia. Chemotherapy can cause bone marrow suppression, which reduces the production of white blood cells, red blood cells, and platelets. This increases the risk of infection, anemia, and bleeding, which can be life-threatening. Therefore, the nurse should monitor the child's blood counts, vital signs, and signs of infection or bleeding, and implement preventive measures such as hand hygiene, isolation, and transfusions.
Choice C reason: Providing age-appropriate activities to promote optimum cognitive and motor skills development is an important nursing goal for a child with leukemia, but it is not the priority. Chemotherapy can cause fatigue, weakness, and neuropathy, which can affect the child's physical and mental abilities. However, these effects can be managed with rest, pain relief, and stimulation.
Choice D reason: Providing emotional support for the child and family members that relieve stress is an important nursing goal for a child with leukemia, but it is not the priority. Chemotherapy can cause anxiety, depression, and fear, which can affect the child's psychological and emotional well-being. However, these effects can be managed with counseling, education, and coping strategies.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Eyes are deviated to the right is an assessment finding that indicates increased intracranial pressure and possible herniation of the brain. It is a sign of cranial nerve III palsy, which affects the movement of the eye and the size of the pupil. It is a medical emergency that requires immediate intervention.
Choice B reason: Amnesia to the cause of the trauma is an assessment finding that indicates memory loss and possible concussion. It is a sign of damage to the temporal lobe, which is involved in memory formation and retrieval. It is not a medical emergency, but it requires further evaluation and monitoring.
Choice C reason: Complaint of mild headache is an assessment finding that indicates pain and discomfort. It is a common symptom of traumatic brain injury, but it is not specific or severe. It can be managed with analgesics and rest.
Choice D reason: Pupils constrict from 5 mm to 2 mm with direct light stimulus is an assessment finding that indicates normal pupillary response. It is a sign of intact cranial nerve II and III function, which control the vision and the pupil size. It is not a cause for concern or notification.
Correct Answer is C
Explanation
Choice A reason: Diabetes mellitus Type 1 is a condition that affects the pancreas and the production of insulin, a hormone that regulates blood sugar levels. It does not directly cause anemia, but it can increase the risk of complications such as infections, ulcers, and nerve damage.
Choice B reason: Peripheral vascular disease is a condition that affects the blood vessels and the circulation of blood to the limbs. It does not directly cause anemia, but it can increase the risk of complications such as clots, wounds, and gangrene.
Choice C reason: Chronic kidney disease is a condition that affects the kidneys and their function of filtering waste and fluids from the blood. It can cause anemia by reducing the production of erythropoietin, a hormone that stimulates the bone marrow to make red blood cells.
Choice D reason: Hypertension is a condition that affects the blood pressure and the force of blood against the artery walls. It does not directly cause anemia, but it can increase the risk of complications such as stroke, heart attack, and kidney damage.
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