Ch 43 Evolve questions

The nurse is caring for a child with leukemia. Which interventions does the nurse implement to reduce the risk for hemorrhage in the child? Select all that apply.

Avoids skin punctures when possible Removes urine immediately after voiding Asks the child to avoid running or biking Provides meticulous mouth care rational: The nurse avoids skin punctures whenever possible to prevent bleeding and reduce the risk for infection. The nurse removes urine and feces immediately because the rectal area is prone to ulceration, which may cause bleeding. Moreover, the nurse asks the child to avoid activities such as running and biking that may increase the chances of injury, resulting in risk for hemorrhage. The nurse provides meticulous mouth care to the child because there is gingival bleeding and mucositis frequently. The nurse does not give a platelet transfusion during a nosebleed; instead, the nurse uses local measures such as applying pressure to the bleeding site to stop the bleeding.

The nurse is caring for a child with thalassemia. What does the nurse observe in this child?

Complications due to blood transfusions rational: Frequent blood transfusions are required for a child with thalassemia to maintain sufficient hemoglobin levels. This may cause iron overload, which is not eliminated and may cause hemosiderosis. So the nurse should be alert to any complications that may develop. Prolonged bleeding is a manifestation of hemophilia and not thalassemia. Epistaxis and bleeding gums are the clinical manifestations of immune thrombocytopenia. Chemotherapy is used for children with child leukemia.

The nurse is providing care to a child who is undergoing chemotherapy for leukemia. What side effects are likely to be expected in the child? Select all that apply.

Nausea and vomiting Anorexia Mucosal ulceration Mood changes rational: Chemotherapy causes nausea and vomiting because several drugs are administered which are not tolerated well by the child's body. It also causes anorexia, as the child feels too sick to eat. There is mucosal ulceration due to drug reaction, which causes difficulty in eating. The child is also given to mood changes induced by the drugs used in the treatment. Enlarged spleen is a symptom of sickle cell anemia.

A child with sickle cell anemia (SCA) has a defective splenic function that increases the child's susceptibility to infections. What does the primary health care provider prescribe?

Pneumococcal vaccines rational: Pneumococcal and meningococcal vaccines are prescribed for a child who is susceptible to infection as a result of functional asplenia. Chronic transfusion therapy is used for children with SCA who are at risk for cerebrovascular accident. ATG is the main drug used for treating aplastic anemia. Oxygen therapy is used in case the child with SCA has hypoxia.

What is administered to a child who presents with hemophilia A and is at risk for joint bleeding?

Primary prophylaxis Rational: Primary prophylaxis is administered to prevent bleeding complications in a child with hemophilia A. The child is administered factor VIII concentrate on a regular basis before the joint damage occurs. Secondary prophylaxis involves administering factor VIII concentrate after the child experiences bleeding in a joint. Anti-D antibody is administered to a child with immune thrombocytopenia (ITP) to prevent bleeding. Intravenous heparin is used to inhibit thrombin formation in clients with ITP.

The nursing instructor is teaching a group of students about hemophilia A. Which statement by the student indicates effective learning?

This condition occurs as a result of the deficiency of antihemophilic factor." rational: Antihemophilic factor is necessary for blood coagulation; hence, hemophilia A occurs if there is a deficiency of antihemophilic factor. Hemophilia A causes bleeding in the subcutaneous tissue, intramuscular tissue, and the joint space because of a lack of clotting factor. The disease gets worse if antihemophilic factor is less in the blood. Patients with hemophilia A have two factors (vascular influence and platelets) required for blood coagulation; hence, they bleed for longer periods but not at a faster rate.

An infant with sickle cell anemia (SCA) is prescribed the hemoglobin electrophoresis test. What is the purpose of this test?

To detect different types of hemoglobin rational: A hemoglobin electrophoresis test is used to detect different types of hemoglobin in the child. It further helps determine whether the child has SCA, the homozygous form of the disease, or sickle cell C disease, the heterozygous form. A transcranial Doppler (TCD) test is used to identify whether the child with SCA is at risk for cerebrovascular accident. Sickledex is used to confirm the presence of sickle cell anemia. Hemoglobin electrophoresis test is not used to rule out disorders other than SCA.

A child with sickle cell anemia develops severe chest pain, fever, a cough, and dyspnea. The first action by the nurse is to:

notify the practitioner because chest syndrome is suspected. rational: Severe chest pain, fever, cough, and dyspnea are signs and symptoms of chest syndrome. The nurse must notify the practitioner immediately. Administration of oxygen may be ordered by the practitioner, but the first action is notification. Oxygen therapy is of little therapeutic value unless the patient has hypoxia. Pain medications may be indicated, but evaluation is necessary first. Demerol is not recommended because it produces a metabolite that is a CNS stimulant causing anxiety, tremors, myoclonus, and seizures. A stroke is not indicated.

The nurse is educating the parents of a child about the symptoms that would indicate sickle cell anemia. Which symptoms does the nurse describe? Select all that apply.

painful joints big and swollen spleen chest pain hypoxia rational: Vasoocclusive crisis is a symptom of sickle cell anemia, which causes painful joints. Big and swollen spleen develops due to pooling of large amount of blood in the spleen. Chest pain is accompanied by fever and hypoxia, which indicates sickle cell anemia

primary therapy for hemophilia

replacement of clotting factors

The nurse suspects that a child with enlarged lymph nodes and fever has leukemia. Which test does the nurse evaluate to confirm the condition?

Bone marrow biopsy rational: Leukemia is confirmed when the bone marrow biopsy indicates that the bone marrow is hypercellular, with primarily blast cells. Peripheral blood smear is not a definite diagnosis of leukemia because it reveals immature forms of leukocytes, frequently combined with low blood counts. Lumbar puncture is performed after a bone marrow biopsy to determine whether there is any involvement of the central nervous system. A tourniquet test helps identify an abnormal platelet count.

The nurse is caring for a child with human immunodeficiency virus (HIV) infection. Which medications does the nurse expect to find in the child's prescription? Select all that apply.

Zidovudine (Retrovir Delavirdine (Rescriptor Nelfinavir (Viracept) Hydroxyurea (Hydrea Rational: Zidovudine (Retrovir) is a nucleoside reverse transcriptase inhibitor. Delavirdine (Rescriptor) is a nonnucleoside reverse transcriptase inhibitor. Nelfinavir (Viracept) is a protease inhibitor, and hydroxyurea (Hydrea) is an adjunctive antiretroviral. These drugs help to slow the growth of the virus and delay the disease progression. Deferoxamine (Desferal) is a parenteral iron-chelating agent used to prevent iron overload during blood transfusions.

The nurse is teaching the parents how to provide care for their child with sickle cell anemia. Which intervention does the nurse include in the teaching?

"Provide daily fluid intake as specified." rational: The parents are instructed about the specific fluid intake of the child for adequate hydration to prevent sickling. The nurse informs that enuresis can be a complication of the disease; so the child should not be scolded or enforced for bladder control. Decreasing spleen is an indication of recovery and not an emergency to be reported. The nurse asks the parents to report immediately if the temperature is more than 101.3 degrees F.

What does the nurse expect the primary health care provider to prescribe for a child with mucositis? Select all that apply.

Aquaphor healing ointment Clotrimazole troche (clotrimazole lozenges Chlorhexidine gluconate (Peridex rational: Aquaphor healing ointment is used to keep the child's lips moist. Clotrimazole troche (clotrimazole lozenges) is used as a mouthwash to reduce bacterial infections. Chlorhexidine gluconate (Peridex) is effective against candidal and bacterial infections

The nurse is caring for a child with severe aplastic anemia. Which treatment of choice is the nurse likely to expect for the child?

Bone marrow transplantation rational: Aplastic anemia causes hypoplasia of the bone marrow. So bone marrow transplantation is the treatment of choice for a child with severe aplastic anemia if a suitable donor is available. Electrolyte replacement is a treatment for sickle cell anemia to prevent the sickling phenomenon. Chemotherapy is used to treat a child with leukemia to work on leukemic cells. Blood transfusions are necessary for patients with thalassemia to maintain sufficient hemoglobin levels.

The nurse is caring for a child with sickle cell anemia (SCA). The child has acute chest syndrome and has also experienced a cerebrovascular accident (CVA). Which is the most effective treatment for the child?

Chronic transfusion therapy rational: Chronic transfusion therapy is used for children with SCA to treat CVA and prevent repeated CVAs. Hemoglobin electrophoresis is a screening test used to identify whether the child has SCA, the homozygous form of the disease, or sickle cell C disease, the heterozygous form. Influenza vaccination is prescribed as an immunization against influenza. Oxygen therapy is used as a treatment if the child has hypoxia.

A 7-month-old girl with sickle cell anemia is not consuming enough fluid orally as she is recovering. What suggestions by the nurse would help the parents best as they prepare to care for their infant daughter after discharge? Select all that apply.

Count the number of bottles or ounces of fluid needed daily. Teach the parents which foods have a high source of fluid. rational: The parents need to learn to count the number of bottles or ounces of fluid needed daily. It is not sufficient to advise parents to "force fluids" or "encourage drinking." They need specific instructions on how many glasses or bottles of fluid are required daily. Many foods are also a source of fluid, particularly soups, flavored ice pops, ice cream, sherbet, gelatin, puddings, canned fruit in liquid, and applesauce. Counting the number of wet diapers helps the parents know whether or not their daughter is consuming enough fluid, but is not a strategy for increasing the infant's oral fluid intake. Parents should not limit liquids before bedtime; enuresis should be considered a complication of the disease, just as joint pain or some other symptom is regarded.

instructing

Encourage participation in swimming Soften toothbrush before brushing Avoid using aspirin for controlling pain rational: The nurse encourages noncontact sports like swimming so that there is no danger of collision and injury. The nurse suggests softening the toothbrush with warm water to prevent trauma to the gums. The nurse also instructs to avoid aspirin or aspirin containing compounds to treat any pain as aspirin worsens bleeding problems. Tennis and golf are noncontact sports and have minimal chances of injury and are not restricted. The nurse can advise to use protective helmets and padding to avoid further injury. Venipunctures are used for blood samples as they cause less bleeding.

Which condition in a child indicates a deficiency of one of the factors (proteins) necessary for blood coagulation?

Hemophilia rational: Hemophilia is a group of bleeding disorders in which there is a deficiency of one of the clotting factors necessary for blood coagulation. Aplastic anemia is characterized by anemia, leukopenia, and decreased platelet count. Sickle cell anemia occurs when normal hemoglobin is replaced by abnormal hemoglobin. Apheresis refers to the process of removing blood from a patient, usually before stem cell transplantation or chemotherapy.

Which symptom is seen in a child with disseminated intravascular coagulation (DIC)?

Increased tendency to bleed rational: A child with DIC has an increased tendency to bleed as a result of excess thrombin and destruction of platelets. Rickettsial infections may sometimes cause DIC. It is not a symptom of DIC. Mucosal inflammation is not a symptom of DIC. It is caused by chemotherapy. Yellow, fatty bone marrow indicates the presence of aplastic anemia.

The health care provider orders a transcranial Doppler (TCD) test for a child with sickle cell anemia (SCA). How does the nurse expect the health care provider to explain the reasoning behind ordering the test? "The test will help us:

Know whether the child is at risk for cerebrovascular accident."

Antithymocyte globulin (ATG) is administered intravenously to a child with aplastic anemia (AA). The child is susceptible to side effects of ATG, such as fever, chills, and myalgias. Which medication is administered to prevent these side effects?

Methylprednisolone (Medrol) rational: Methylprednisolone (Medrol) is administered to prevent fever, chills, and myalgias in a child who is administered ATG intravenously. Prophylactic antibiotics are administered to prevent infections. Stavudine (Zerit) is a class of antiretroviral drugs used in patients with human immunodeficiency virus (HIV) infection. Pentam (Pentamidine) is used for patients with Pneumocystis carinii pneumonia (PCP).

A first-born 7-month-old of African American heritage has a sudden onset of uncontrollable screaming and crying and is brought to the emergency room. The infant and his or her parents are visiting from a country in the Caribbean. After determining that there is no injury present, what actions would the nurse expect to take?

Ask the parents if their child had any recent vomiting, diarrhea, or fever recently. rational: The sickling phenomenon usually is not apparent until later in infancy because of the presence of fetal hemoglobin. This protects the infant from the effects of sickle cell-related complications, but this protection rapidly decreases during the first year. Triggers for a sickle cell crisis can be dehydration, which can occur from vomiting, diarrhea, or fever, as well as from infection. The infant's recent health history and blood work can provide the most information about the presence of sickle cell anemia (SCA). The parents might not have any knowledge that they are carriers of this condition. Newborn screening for SCA is mandatory in most of the United States so that infants can be identified before symptoms occur; most likely this was not done where the child was born.

The nurse finds that the hemoglobin levels in a child with anemia did not improve after taking oral iron supplements. What actions does the nurse take? Select all that apply.

Ask the parents if they administered the prescribed doses Assess whether the child has gastrointestinal problems Assess the child for chronic hemoglobinuria. rational: If the hemoglobin levels in the child do not increase 1 month after taking oral iron supplements, the nurse should assess for noncompliance. The nurse should ask the parents if the prescribed dose consistency was maintained to assess the cause of iron deficiency. The nurse also assesses whether the child has any gastrointestinal problems that may have caused bleeding and blood loss. The nurse assesses whether the child has chronic hemoglobinuria, that is, the presence of protein hemoglobin in urine; this may cause iron deficiency. Providing iron-rich foods will be inadequate if the child has problems such as bleeding or hemoglobinuria. The nurse does not advise to provide fresh cow's milk because it is a poor source of iron and interferes with the absorption of iron. Fresh cow's milk is also avoided in infants younger than 12 months because of risk for gastrointestinal blood loss.

A child with leukemia is treated with chemotherapeutic agents in different phases. Which are the treatment phases? Select all that apply.

Induction therapy Prophylactic therapy Intensification therapy Maintenance therapy rational: Induction therapy achieves a complete remission or less than 5% leukemic cells in the bone marrow. Prophylactic therapy prevents leukemic cells from invading the central nervous system. Intensification therapy eradicates residual leukemia cells. Maintenance therapy serves to maintain the remission phase. Antiretroviral therapy is used for children infected with human immunodeficiency virus (HIV) infection.

The nurse is assessing an adolescent with hemophilia A, who has also experienced several episodes of joint bleeding. Which condition will be evident in the adolescent?

Bony changes rational: Several episodes of joint bleeding over several years lead to bony changes and crippling deformities in a child. Fanconi syndrome is a hereditary disorder that causes pancytopenia, hypoplasia of the bone marrow, and patchy brown discoloration of the skin. Delayed sexual maturation is sometimes a side effect of chemotherapy and irradiation. Visual disturbances occur in a child with sickle cell anemia as a result of chronic vasoocclusive phenomena.

The nurse is caring for a child with severe anemia. The child has to undergo several blood tests. What actions does the nurse take to prepare the child for the test? Select all that apply.

Explains why all the tests are necessary Demonstrates the procedure on a doll Describes the test step by step rational: The child with severe anemia has to undergo several tests sequentially, which is traumatic for the child. So the nurse explains the purpose of each test to provide comfort to the child. The nurse demonstrates the procedure on the doll so that the child gets familiar with the procedure. The nurse describes the test step by step at the level of the child's understanding so that the child gets comfortable with the procedure. The nurse tells the parents to accompany the child during the procedure to make the latter comfortable. The nurse is responsible for preparing the child for the test.

Which condition does the nurse ask the parents of a child with non-Hodgkin lymphoma (NHL) to report after irradiation?

Fatigue Rational: The most common side effect of irradiation in children with NHL is fatigue. The nurse informs the parents to be alert for the signs of fatigue such as falling asleep at the dinner table or being unable to concentrate on homework. Bleeding is seen in children with hemophilia. Abdominal pain is seen in children with sickle cell anemia. Eczema is seen in children with Wiskott-Aldrich syndrome.

A 5-month-old infant born to a mother with human immunodeficiency virus (HIV) infection needs to be tested for HIV. Which test will be used for an accurate diagnosis of HIV in the child?

HIV polymerase chain reaction rational: HIV polymerase chain reaction is used for detecting proviral DNA in infants between 1 and 6 months of age. Western blot immunoassay and HIV enzyme-linked immunosorbent assay are used in detecting HIV in infants who are aged 18 months or older. In younger infants, these assays are positive because maternal antibodies are derived transplacentally by the child. Partial thromboplastin time test is used to detect hemophilia.

The nurse is assessing a child with short stature and malnutrition. The medical history of the child also indicates oral candidiasis. Which condition does the nurse suspect in the child?

Human immunodeficiency virus rational: Short stature, malnutrition, and oral candidiasis are the symptoms of human immunodeficiency virus (HIV) infection. Developmental delay and chronic or recurrent diarrhea are the other symptoms associated with HIV. Non-Hodgkin lymphoma is a type of blood cancer characterized by swollen lymph nodes and fever. Disseminated intravascular coagulation is characterized by an increased tendency to bleed resulting from the destruction of platelets. Immune thrombocytopenia is characterized by easy bruising, mucosal bleeding, and petechiae caused by abnormal platelet count.

The nurse is reading the reports of a child with aplastic anemia (AA). Which findings indicate that the child has severe AA? Select all that apply.

Less than 25% bone marrow cellularity Absolute reticulocyte count less than 40,000/mm3 Absolute granulocyte count less than 500/mm3 Platelet count less than 20,000/ mm3 Rational: Aplastic anemia (AA) is diagnosed from bone marrow examination in which there is conversion of red bone marrow to yellow, fatty bone marrow. The severity of anemia is indicated if there is less than 25% bone marrow cellularity with absolute reticulocyte count less than 40,000/mm3, absolute granulocyte count less than 500/mm3, and platelet count less than 20,000/ mm3. Presence of mild or moderate cytopenia and more than 25% bone marrow cellularity indicates moderate AA.

The blood report of a 5-year-old child reveals a reduction in hemoglobin below the normal value concentration. Which physiologic defect does the nurse expect in the child?

Reduction in oxygen-carrying capacity of blood rational: The reduction in hemoglobin below the normal value indicates anemia. The physiologic defect associated with anemia is a reduction in the oxygen-carrying capacity of the blood. Iron deficiency anemia is found mostly in children between 12 to 36 months. It is caused by the insufficient consumption of foods rich in iron. Cyanosis is caused by deoxygenated hemoglobin in arterial blood. Bone marrow failure is determined only from bone marrow examination.

The nurse is monitoring a child during a blood transfusion procedure. What precautions does the nurse take? Select all that apply.

Takes vital signs before, after, and during the blood transfusion Administers the first 50 mL of blood volume slowly Uses an appropriate filter for administering blood Stops the transfusion if there is any reaction in the child rational: The nurse takes vital signs before the blood transfusion to establish baseline data for intratransfusion. Vital signs are taken hourly while the blood is infusing and taken posttransfusion to check for any adverse reactions. The nurse administers the first 50 mL of the blood volume slowly to prevent any abnormalities in the blood pressure and assess for adverse reactions. If there is any reaction in the child, the nurse stops the transfusion, takes vital signs, and maintains a patent I.V. line with normal saline and new tubing. The nurse then informs the primary health care provider. The nurse uses an appropriate filter for administering blood to eliminate any particles in the blood. The nurse uses the blood within 30 minutes of its arrival from the blood bank so that the blood properties do not change.

The nurse suspects that a child is having an adverse reaction to a blood transfusion. The first action by the nurse should be to:

stop transfusion and maintain a patent intravenous line with normal saline and new tubing. rational: Stopping the transfusion is the priority nursing action. If an adverse reaction is occurring, it is essential to minimize the amount of blood that is infused. Notifying the physician and taking vital signs should be performed after the blood transfusion is stopped and infusion of normal saline has begun. Blood should not be diluted; it should be returned to the blood bank if an adverse reaction has occurred.