The nurse is caring for a child who is receiving chemotherapy for the treatment of leukemia and plans to address the expected needs of this client? Select all that apply.
Excessive hair growth
Increased appetite
Fatigue
Possible infections
Easy bruising
Correct Answer : C,D,E
A. Excessive hair growth: Hair loss, not excessive hair growth, is a common side effect of chemotherapy.
B. Increased appetite. Chemotherapy often causes nausea, vomiting, and reduced appetite, not an increase in appetite.
C. Fatigue. Fatigue is a common side effect of chemotherapy due to its impact on the body, including reduced blood counts and overall systemic stress.
D. Possible infections: Chemotherapy weakens the immune system, increasing the risk of infections. The nurse will monitor the child for signs of infection and implement measures to prevent them, like proper hand hygiene and maintaining a clean environment.
E. Easy bruising: Chemotherapy can affect blood clotting, making the child more susceptible to bruising. The nurse will educate the parents and child about precautions to minimize bruising risks
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
i. Pain:
Priority: Pain is a critical factor that needs immediate attention, especially since the adolescent reports a high pain level of 9/10, which indicates severe discomfort. Unmanaged pain can lead to increased stress, anxiety, and potentially worsen the patient’s condition. The adolescent is guarding the abdomen, which indicates severe pain possibly due to an underlying issue such as appendicitis or another serious abdominal pathology. The right lower quadrant pain and positive obturator sign suggest an acute abdomen, which could be life-threatening and requires urgent attention.
ii. Heart rate:
Priority: After addressing pain, the nurse should focus on the heart rate, which is elevated at 124 beats per minute (tachycardia). Tachycardia in this context could be a response to pain or an indication of infection, dehydration, or another serious underlying condition. Given that the temperature is slightly elevated (38°C or 100.4°F), there is a possibility of an infectious process, which could be contributing to both pain and the elevated heart rate.
Other Considerations:
- Nausea: Addressing nausea is important but secondary to the more urgent need to manage severe pain and evaluate cardiovascular stability.
- Bowel Movement: The last bowel movement was yesterday, and the patient does not report significant changes in bowel habits, making this less urgent than the acute symptoms.
- WBC Count: While it’s important to assess WBC count to check for infection, it’s part of a broader diagnostic workup that follows after addressing immediate symptoms.
- Decreased Appetite: This is a symptom of the underlying condition but is not as immediate a concern as pain and heart rate in the acute setting.
Correct Answer is C
Explanation
A. Diarrhea: Diarrhea is not a typical finding associated with Wilms' tumor.
B. Swollen joints: Swollen joints are not associated with Wilms' tumor and would suggest a different condition.
C. Abdominal mass: Wilms' tumor typically presents with an asymptomatic abdominal mass that may be firm, non-tender, and palpable.
D. Jaundice: Jaundice is not typically associated with Wilms' tumor and would suggest liver dysfunction or another underlying cause.
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