The parents of a child with acute lymphoblastic leukemia (ALL) are learning to care for their child at home. Which statement made by the parents should the nurse recognize as correct monitoring for early signs of an infection in the child?
Reassess axillary temperature if it is higher than 99.7° F (37.6° C).
Verify if the child has a fever by checking a rectal temperature.
Notify for a temporal temperature greater than 100° F (37.8° C).
Check temperature twice a day with an aural thermometer.
The Correct Answer is C
Choice A reason: Reassessing axillary temperature if it is higher than 99.7° F (37.6° C) is not a correct monitoring for early signs of an infection in the child. Axillary temperature is not the most accurate method of measuring body temperature, especially in children. It can be affected by factors such as clothing, sweating, and room temperature. Axillary temperature is usually lower than the core body temperature by about 1° F (0.6° C). Therefore, a child with an axillary temperature higher than 99.7° F (37.6° C) may already have a significant fever and should be evaluated by a health care provider.
Choice B reason: Verifying if the child has a fever by checking a rectal temperature is not a correct monitoring for early signs of an infection in the child. Rectal temperature is the most accurate method of measuring body temperature, but it is also the most invasive and uncomfortable. It can cause irritation, bleeding, or injury to the rectum, especially in children with low platelet counts or bleeding disorders. Rectal temperature is also not recommended for children with acute lymphoblastic leukemia, as it can increase the risk of introducing bacteria or fungi into the bloodstream.
Choice C reason: Notifying for a temporal temperature greater than 100° F (37.8° C) is a correct monitoring for early signs of an infection in the child. Temporal temperature is a noninvasive and convenient method of measuring body temperature, using an infrared scanner that detects the heat emitted by the temporal artery on the forehead. Temporal temperature is comparable to the core body temperature and can reflect changes in body temperature quickly. A child with acute lymphoblastic leukemia who has a temporal temperature greater than 100° F (37.8° C) may have an infection and should be reported to the health care provider immediately.
Choice D reason: Checking temperature twice a day with an aural thermometer is not a correct monitoring for early signs of an infection in the child. Aural temperature is a noninvasive and easy method of measuring body temperature, using an infrared sensor that detects the heat emitted by the tympanic membrane in the ear. However, aural temperature can be inaccurate or unreliable, as it can be affected by factors such as earwax, ear infections, ear canal shape, and ambient noise. A child with acute lymphoblastic leukemia who has a fever may not be detected by an aural thermometer, and may miss the opportunity for early intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Changing position every 2 hours is not the most important intervention that the nurse should implement. This is because the child's position is limited by the traction and the splint, and frequent repositioning may interfere with the alignment and stability of the fracture. The nurse should only change the position of the child as ordered by the physician and with the assistance of another nurse.
Choice B reason: Assessing skin for redness and signs of tissue breakdown is not the most important intervention that the nurse should implement. This is because the skin is not directly in contact with the traction or the splint, and the risk of pressure ulcers is low. The nurse should still inspect the skin regularly and provide skin care as needed, but this is not the priority.
Choice C reason: Cleansing pin sites as prescribed is not the most important intervention that the nurse should implement. This is because the pin sites are not the main source of infection or complication in this type of traction. The nurse should still follow the protocol for pin site care and monitor for signs of infection, such as redness, swelling, drainage, or odor, but this is not the priority.
Choice D reason: Monitoring peripheral pulses and sensation in the right leg is the most important intervention that the nurse should implement. This is because the traction and the splint can impair the circulation and nerve function of the affected extremity, leading to complications such as compartment syndrome, ischemia, or nerve damage. The nurse should check the pulses, temperature, color, capillary refill, and sensation of the right leg at least every hour and report any changes or abnormalities to the physician.
Correct Answer is D
Explanation
Choice A reason: Encouraging the parent to come to the clinic if the child develops a fever is not the best response that the nurse can give. This is because a fever may indicate a serious infection, such as Lyme disease, that requires prompt treatment. The nurse should not wait for the child to develop a fever before advising the parent to seek medical attention.
Choice B reason: Instructing the parent to apply an antihistamine ointment for one week is not the best response that the nurse can give. This is because an antihistamine ointment may not be effective for a fungal infection, such as ringworm, or a bacterial infection, such as Lyme disease, that may cause a circular rash. The nurse should not recommend any OTC product without knowing the exact cause of the rash.
Choice C reason: Offering reassurance that OTC corticosteroid creams are safe and effective is not the best response that the nurse can give. This is because corticosteroid creams may worsen a fungal infection, such as ringworm, or mask the symptoms of a bacterial infection, such as Lyme disease, that may cause a circular rash. The nurse should not recommend any OTC product without knowing the exact cause of the rash.
Choice D reason: Explaining the need for the child to have an immediate medical evaluation is the best response that the nurse can give. This is because a circular rash can be a sign of a serious condition, such as Lyme disease, that requires urgent diagnosis and treatment. The nurse should inform the parent that the rash may not be ringworm, as many people assume, and that it may be caused by a tick bite or another factor. The nurse should also advise the parent to avoid touching or scratching the rash and to keep it clean and dry until the child sees a doctor.
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