Which nursing diagnosis is the priority for the child newly diagnosed with leukemia?

Disturbed body image related to alopecia

Ineffective breathing pattern related to mediastinal disease

Risk for infection related to immunosuppressed state

Impaired skin integrity related to radiation therapy

Answer and Explanation

The Correct Answer is C

A. While important for psychosocial support, this is not the immediate priority. Hair loss occurs later with chemotherapy and does not pose an immediate threat to life.

B. This would be a priority if the child presented with respiratory distress, such as dyspnea, stridor, or cyanosis. In a newly diagnosed child without respiratory symptoms, it is less urgent than addressing infection risk.

C. This is the priority nursing diagnosis. Children with leukemia have a suppressed immune system due to both the disease and chemotherapy. Infection can progress rapidly and become life-threatening (sepsis). Nursing interventions focus on strict hand hygiene, limiting exposure to infectious agents, monitoring for signs of infection (fever, tachycardia, hypotension), and educating caregivers. Early prevention and prompt intervention are essential to reduce morbidity and mortality.

D. This is not relevant for a newly diagnosed child, as radiation therapy is typically initiated later. Skin integrity issues are secondary concerns compared with immediate infection risk.

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Correct Answer is D

Explanation

A. Scoliosis braces, such as the thoracolumbosacral orthosis (TLSO), are most effective when worn for the prescribed duration, usually 18–23 hours per day. Removing the brace outside of approved times can reduce its effectiveness in preventing curve progression. Temporary removal due to fatigue is not recommended.

B. Most scoliosis braces need to be worn for several years or until skeletal maturity is reached, depending on the severity of the curve. Expecting only 6 months is a misconception and indicates a lack of understanding about the long-term nature of treatment.

C. Braces should not be removed for social events. Compliance is crucial for treatment success. This statement reflects misunderstanding of the importance of consistent brace use.

D. Approved brief removal of the brace for hygiene purposes is acceptable and safe. This statement demonstrates that the child understands the proper use of the brace, including that removal should be limited and purposeful, and that the brace should otherwise be worn as prescribed to manage scoliosis effectively.

A. Plan to add additional weights as the fracture heals, usually once per day. B. Ensure traction weights are hanging freely, not touching the bed or floor. C. Remove traction weights once per shift for 30 minutes and then replace them. D. Have the unlicensed assistive personnel remove the weights daily and encourage the child to move around in bed.

Correct Answer is B

Explanation

A. Traction weights are prescribed by the healthcare provider and should not be adjusted by the nurse unless specifically ordered. Changing weights without an order can compromise fracture alignment or cause injury.

B. Proper traction requires constant, uninterrupted force to maintain fracture alignment. Weights must hang freely to provide the correct pull; if they touch the bed or floor, traction effectiveness is lost, potentially delaying healing or causing malalignment. This is a fundamental aspect of safe traction care.

C. Traction weights are continuous unless ordered to be temporarily released for specific procedures. Routine removal disrupts the therapeutic force and can interfere with fracture healing or cause complications.

D. Traction management is a licensed nursing responsibility, especially when it involves weights and maintaining proper alignment. UAPs can assist with positioning or hygiene, but they should not remove weights, and ambulation is generally restricted depending on fracture type and traction method.

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Which nursing diagnosis is the priority for the child newly diagnosed with leukemia?

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Naxlex Comprehensive Predictor Exams

The nurse is doing client teaching with a child who has been placed in a brace to treat scoliosis. Which statement made by the child indicates an understanding of treatment?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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Which nursing diagnosis is the priority for the child newly diagnosed with leukemia?

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