Flashcards in Chapter 26 Deck (18):
The nurse is explaining blood components to an 8-year-old child. Based on the nurse’s knowledge of child development, the most appropriate description of platelets is that they
a. help keep germs from causing infection.
b. make up the liquid portion of blood.
c. carry the oxygen you breathe from your lungs to all parts of your body.
d. help your body stop bleeding by forming a clot (scab) over the hurt area.
Platelets are involved in homeostasis.
This is the function of white blood cells.
This is a definition of plasma.
This is the function of the red blood cells.
The parent of a child receiving an iron preparation tells the nurse that the child's stools are a tarry black color. The nurse should explain that this is
a. a symptom of iron deficiency anemia.
b. an adverse effect of the iron preparation.
c. an indicator of an iron preparation overdose.
d. a normally expected change due to the iron preparation.
An adequate dosage of iron turns the stools a tarry black color.
Tarry black stools are not a sign of iron deficiency anemia.
Tarry black stools are not an adverse effect of the iron preparation but an expected effect.
Tarry black stools are not an indicator of iron preparation overdose.
The parents of a child with sickle cell anemia (SCA) are concerned about subsequent children having the disease. Which response by the nurse is most accurate?
a. “SCA is not inherited.”
b. “All siblings will have SCA.”
c. “There is a 25% chance of a sibling having SCA.”
d. “There is a 50% chance of a sibling having SCA.”
SCA is inherited as an autosomal recessive disorder. In this inheritance pattern, there is a 25% chance that each subsequent child will have the disorder.
SCA is an inherited hemoglobinopathy.
In autosomal recessive disorders, there is a chance that 25% of the children will not have either SCA or sickle cell trait.
There is a chance that 50% of the siblings will have sickle cell trait.
What is the most important nursing consideration when caring for a child with sickle cell anemia?
a. Teach the parents and child how to minimize crises.
b. Refer the parents and child for genetic counseling.
c. Help the child and family to adjust to a short-term disease.
d. Observe for complications of multiple blood transfusions.
Children and their families need specific instructions on how to minimize crises, including preventing infections; maintaining adequate hydration; and addressing environmental concerns, such as avoidance of extreme cold.
Genetic counseling is important, but teaching care for the child is a priority.
Sickle cell anemia is a long-term, chronic illness.
Multiple blood transfusions are an option for some children with sickle cell disease. The priority is that the child and the parents are properly prepared to manage the chronic disease.
A child with sickle cell anemia develops severe chest pain, fever, a cough, and dyspnea. The nurse's first action is to
a. administer 100% oxygen to relieve hypoxia.
b. administer pain medication to relieve symptoms.
c. notify practitioner because chest syndrome is suspected.
d. notify practitioner because child may be having a stroke.
Severe chest pain, fever, a cough, and dyspnea are the signs and symptoms of chest syndrome. The nurse must notify the practitioner immediately.
Breathing 100% oxygen to relieve hypoxia may be ordered by the practitioner, but the first action is notification because these symptoms indicate a medical emergency.
Pain medications may be indicated, but evaluation is necessary first.
Severe chest pain, fever, cough, and dyspnea are not signs of a stroke.
The school nurse is caring for a boy with hemophilia who fell on his arm during recess. What supportive measures should the nurse use until factor replacement therapy can be instituted?
a. Apply warm, moist compresses.
b. Apply pressure for at least 1 minute.
c. Elevate the area above the level of the heart.
d. Begin passive range-of-motion unless the pain is severe.
The initial response should include elevation of the arm to minimize bleeding.
Cold should be applied to the arm. This will aid in vasoconstriction, minimizing blood loss.
Pressure is effective in small areas but would not be as effective for an extremity.
Passive range-of-motion is not recommended. The child can perform active range-of-motion after the bleeding episode has resolved.
What is the most appropriate action to stop an occasional episode of epistaxis?
a. Have the child sit up and lean forward.
b. Apply ice under the nose and above the lip.
c. Have the child lie down quietly with the feet elevated.
d. Apply continuous pressure to the nose with the thumb and forefinger for at least 1 minute.
Sitting up and leaning forward is the position used to prevent the child from aspirating blood.
Pressure, not ice, is indicated for an occasional episode of epistaxis.
Lying the child down with the feet elevated can potentially lead to aspiration.
Continuous pressure for 10 minutes is recommended; 1 minute would not be long enough.
What are the most common signs and symptoms of leukemia related to bone marrow involvement?
a. Petechiae, infection, fatigue
b. Headache, papilledema, irritability
c. Muscle wasting, weight loss, fatigue
d. Decreased intracranial pressure, psychosis, confusion
Petechiae, infection, and fatigue are signs of infiltration of the bone marrow. Petechiae occur from a lowered platelet count, infection occurs from the depressed number of effective leukocytes, and fatigue occurs from the anemia.
Headache, papilledema, and irritability are not signs of bone marrow involvement.
Muscle wasting, weight loss, and fatigue are not signs of bone marrow involvement.
Decreased intracranial pressure, psychosis, and confusion are not signs of bone marrow involvement.
Nursing care of the child with myelosuppression from leukemia or chemotherapeutic agents should include to
a. restrict oral fluids.
b. institute strict isolation.
c. use good hand-washing technique.
d. give immunizations appropriate for age.
Good hand-washing technique is the most effective means to prevent disease transmission in children with myelosuppression.
There is no indication to reduce fluids in children with myelosuppression.
Strict isolation is not necessary in children with myelosuppression.
The child should not receive any live vaccines, because the immune system is not capable of responding appropriately to them.
The nurse suspects a child is having an adverse reaction to a blood transfusion. What should the nurse's first action be?
a. Notify the physician.
b. Take vital signs and blood pressure and compare them with baseline values.
c. Dilute infusing blood with equal amounts of normal saline.
d. Stop the transfusion and maintain a patent intravenous line with normal saline and new tubing.
The priority nursing action is to stop the transfusion and maintain a patent intravenous line with normal saline and new tubing. If an adverse reaction is occurring, it is essential to minimize the amount of blood that is infused into the child.
The physician should be notified after the blood transfusion is stopped and normal saline is infusing.
Vital signs should be assessed after the blood transfusion is stopped and normal saline is infusing.
Blood should not be diluted; it should be returned to the blood bank if an adverse reaction has occurred.
The school nurse is explaining to a child's kindergarten teacher that the child is allergic to peanuts. The nurse should include information that
a. the child will most likely outgrow the allergy soon.
b. the child should have an injectable epinephrine cartridge available at all times.
c. the child allergic to peanuts can usually have peanut butter, but not whole peanuts.
d. the child usually only shows skin signs such as hives when allergic.
Exposure to peanuts can result in a severe allergic, potentially life-threatening reaction, such as anaphylaxis and shock. Immediate treatment to prevent such reactions includes the injection of epinephrine; therefore, this should be available at all times wherever the child is within the school premises.
Peanut allergies may be lifelong.
Children allergic to peanuts are allergic to all peanut products, whole and processed. They should have no peanut-containing products at all.
The signs and symptoms of an allergic reaction to peanuts may vary from individual to individual.
The school nurse is discussing prevention of acquired immunodeficiency syndrome (AIDS) with some adolescents. Which statement is appropriate to include?
a. The virus is easily transmitted.
b. The virus is transmitted only through blood.
c. Intravenous drug users should not share needles.
d. Condoms should be used if a person is sexually active and homosexual.
Human immunodeficiency virus (HIV) is spread through blood and body fluids. Intravenous needles that have been used should not be shared. They may be contaminated with the virus.
The virus is not easily transmitted. It requires direct contact with blood or body fluids on a nonintact skin surface.
Body fluids may also transmit the virus.
Condoms should be used for both heterosexual and homosexual sex.
Therapeutic management of the patient with systemic lupus erythematosus (SLE) includes
a. application of cold salts to suppress the inflammatory process.
b. a high-protein, low-salt diet.
c. a rigorous exercise regimen to build up muscle strength and endurance.
d. administration of corticosteroids to control inflammation.
Corticosteroid administration is the primary mode of therapy currently for SLE.
The application of cold salts will not affect the inflammatory process associated with SLE.
A balanced diet without exceeding caloric expenditures is recommended.
Exercise should be done in moderation.
A child with β-thalassemia is receiving numerous blood transfusions. In addition, the child is receiving deferoxamine (Desferal) therapy. The child’s parents ask the nurse what deferoxamine does. The most appropriate response by the nurse is
a. “The medication helps to prevent blood transfusion reactions.”
b. “The medication stimulates red blood cell production.”
c. “The medication provides vitamin supplementation.”
d. “The medication helps to prevent iron overload.”
A side effect of hypertransfusion therapy is often iron overload. Deferoxamine is an iron-chelating drug that binds excess iron; therefore, it can be excreted by the kidneys.
Deferoxamine does not prevent blood transfusions.
Deferoxamine does not stimulate red cell production.
Deferoxamine is not a vitamin supplement.
Nursing considerations related to the administration of chemotherapeutic drugs include
a. Many chemotherapeutic agents are vesicants that can cause severe cellular damage if the drug infiltrates
b. Good hand washing is essential when handling chemotherapeutic drugs, but gloves are not necessary
c. Infiltration will not occur, unless superficial veins are used for the intravenous infusion
d. Anaphylaxis cannot occur, because the drugs are considered toxic to normal cells
Chemotherapeutic agents can be extremely damaging to cells. Nurses experienced with the administration of vesicant drugs should be responsible for giving these drugs and prepared to treat extravasations if necessary.
Gloves are worn to protect the nurse when handling the drugs, and the hands should be thoroughly washed afterward.
Infiltration and extravasations are always a risk, especially with peripheral veins.
Anaphylaxis is a possibility with some chemotherapeutic and immunologic agents, including asparaginase (Elspar).
What is appropriate mouth care for a toddler with mucosal ulceration related to chemotherapy?
a. Lemon glycerin swabs for cleansing
b. Mouthwashes with normal saline
c. Mouthwashes with hydrogen peroxide
d. Local anesthetic such as viscous lidocaine before meals
Normal saline mouthwashes are the preferred mouth care for this age group. The rinse will keep the mucosal surfaces clean without adverse effects on mucosa or problems if the child swallows the rinse.
Lemon glycerin swabs can irritate eroded tissue and can decay teeth.
Hydrogen peroxide delays healing by breaking down protein.
Viscous lidocaine is not recommended for toddlers, because it depresses the gag reflex and the child may have resultant aspiration.
A child with lymphoma is receiving extensive radiotherapy. What is the most common side effect of this treatment?
Fatigue is the most common side effect of radiotherapy. For children, the fatigue may be distressing because they cannot keep up with their peers.
Seizures are unlikely, because irradiation would not usually be cranial for lymphoma.
Neuropathy is a side effect of certain chemotherapeutic agents but not of radiotherapy.
Lymphadenopathy is one of the findings of lymphoma, not a side effect of radiotherapy.