Rationalization
Which of the following is not expected on a child
4th lecture exam
1. A 4-year-old child is admitted to the hospital for
abdominal pain. The mother reports that the child
has been pale and excessively tired and is bruising
easily. On physical examination, lymphadenopathy
and hepatosplenomegaly are noted. Diagnostic
studies are being informed because acute
lymphocytic leukemia is suspected. The nurse
determines that which laboratory findings?
Ans: bone marrow biopsy showing blast cells
2. A 6-month-old infant receives a diphtheria, tetanus,
and acellular pertussis (DTaP) immunization at the
well-baby clinic. The parent returns home and calls
the clinic to report that the infant has developed
swelling and redness at the site of injection. Which
instruction by the nurse is appropriate?
ANS: apply an ice pack to the injection site
3. A bone marrow transplant is being considered for
treatment of a patient with acute leukemia that has
not responded to chemotherapy, in discussing the
treatment with the patient, the nurse explains that:
Ans: hospitalization will be required for several
weeks after the hematopoietic stem cell
transplant
4. A child is diagnosed with chicken pox. The nurse
collects data regarding the child. Which finding is
characteristics of chicken pox?
Ans: macular rash on the trunk and scalp
5. A child is seen in the pediatrician’s office for
complaints of bone and joint pain. Which of the
following other assessment findings may suggest
leukemia?
Ans: petechiae
6. A male client with a nagging cough makes an
appointment to see the physicians after reading
that this symptom is one of the seven warning signs
of cancer. What is another warning sign of cancer?
Ans: indigestion
7. A mother brings her child to the health care clinic
because the child has developed lesions located
around the mouth and mild impetigo is diagnosed.
The nurse reinforces instructions to the mother
regarding care of the child. Which statements of the
mother indicates the need for further teaching?
Ans: ” the crusts on the lesions need to be
soaked and carefully removed”
8. A nurse is assessing an infant who has eczema.
with eczema?
Ans: ecchymosis in flexural areas
9. A nurse is assessing a child who has
rhabdomyosarcoma of the upper arm. Which of the
following findings is not consist of
rhabdomyosarcoma?
Ans: easy bruising
10. A nurse is assessing an infant who has scabies.
Which of the following findings is not expected of
scabies?
Ans: presence of nits on the hair shafts
11. A nurse is caring for a child who has contact
dermatitis due to poison ivy. Which of the following
actions should the nurse..
Ans: remove the clothing over the rash and
apply calamine lotion to the skin.
12. A nurse is caring for a client who has superficial
partial-thickness burn. Which of the following
actions should the nurse take?
Ans. Apply cool, wet compress to the affected
areas.
13. A nurse is caring for a client who has major burns
and suspected septic shock. Which of the following
actions should the nurse take first?
Ans: altered sensorium
14. A nurse is caring for an adolescent who has a new
diagnosis of osteosarcoma. Which of the following
actions should the nurse take first?
Ans: prepare a teaching plan to educate the
adolescent in detail about the diagnosis and
treatment.
15. A nurse is planning for a child who has tine capitis.
Which of the following actions should the nurse
include in the plan of care?
Ans: treat infected house pets
16. A nurse is planning for a child who has diaper
dermatitis. Which of the following actions should
the nurse include in the plan of care?
Ans: allow the buttocks to air dry.
17. A nurse is planning care foe an infant who is
scheduled to have a lumbar puncture. Which of the
following actions should the nurse include in the
plan of care?
Ans: apply a eutectic mixture of local
anesthetics cream just the procedure begins
18. A nurse is preparing to administer the varicella
vaccine to an adolescent. Which of the following
 statements should the nurse ask to determine
whether there is contraindication to administering
the vaccine?
Ans: “are you currently taking corticosteroid
medication?”
19. A nurse is teaching a group of parents about
preventing insects’ bites. Which of the following
information should the nurse include in the
teaching? SATA
Ans: B,D,E
20. A nurse is teaching a group of adolescents about
HIV/AIDS. Which of the following information
should the nurse include in the teaching?
ANS: “HIV is transmitted through IV substance use”
21. A nurse is teaching a parent of a child who has
pediculosis capitis. Which of the following
instructions should the nurse include in the
teaching?
Ans: use an over-the-counter medication
containing 1% permethrin.
22. A nurse is teaching the guardian of an infant who
has seborrheic dermatitis of the scalp. Which of the
following instructions should the nurse include in
the teaching?
Ans: you can use petrolatum to help soften and
remove patches from your infants scalp.
23. A patient who has been told by the health care
provider that the cells in a bowel tumor are poorly
differentiated ask the nurse what is meant by
“poorly differentiated” which responds should the
nurse make?
Ans: your tumor cells look more like immature
fetal cells than normal bowel cells
24. A “white strawberry tongue” is a clinical
manifestation of which infectious disease?
Ans: scarlet fever
25. Bone marrow transplantation is considered
standard therapy for which childhood cancer?
Ans: acute myelocytic leukemia
26. For a female client with newly diagnosed cancer,
nurse formulates a nursing diagnosis of anxiety
related to the treat of the death, secondary to
cancer diagnosis. Which expected outcomes would
be appropriate for this client?
Ans: client verbalizes feeling of anxiety
27. Maria was recently was recently diagnosed with
Hodgkin’s lymphoma. Upon the early diagnosis, the
nurse will expect which of the following are often
involve?
Ans: neck
28. Nausea and vomiting are common adverse effects
of radiation and chemotherapy, when should the
nurse administer antiemetics?
Ans: 30 minutes before the initiation of therapy
29. Nausea and vomiting are expected side effects of
chemotherapeutic drug use. Which of the following
drugs should be administered to a client on
chemotherapy to prevent nausea and vomiting?
Ans: metozol (metoclopramide)
30. Neoplasm can be classified as either benign or
malignant. The following are characteristics of
malignant tumor apart from:
Ans: encapsulated
31. On a clinic visit a client has a relative with cancer, is
asking about the warning signs that may relate to
cancer. The nurse correctly identifies the warning
signs of cancer by responding:
Ans: sudden weight loss of unexplained etiology
can be a warning sign of cancer.
32. The mother of a toddler with mumps ask the nurse
what she needs to watch for in her child with this
disease. The nurse bases the response on the
understanding that mumps is which type of
communicable disease?
Ans: Respiratory disease caused by a virus
involving the parotid gland.
33. The nurse monitoring a child for bleeding after a
surgery for removal of brain tumor. The nurse
checks the head dressing for the presence of blood
and notes a colories drainage on the back of the
dressing. Which action should the nurse perform
immediately?
Ans: notify the surgeon
34. The nurse is reviewing the chart of a client who is
newly diagnosed with chronic lymphocytic
leukemia. Which of the following laboratory values
is expected to be seen?
Ans: thrombocytopenia and increased lymphocytes
35. The nurse is teaching the parent of a 15-year-old
with Infectious mononucleosis. Which statement
made by the parent would indicate an
understanding of the teaching?
Ans: I should offer my child soothing liquids and
bland foods for a sore throat
36. The nurse reinforces home care instructions to the
parents of a child hospitalized with pertussis. The
child is in the convalescent stage and is being
 prepared for discharge. Which statement by the 49. Which position is contraindicated for a child after
parents indicates a need for further teaching? surgery to remove a brain tumor?
Ans: we need to maintain respiratory precautions Ans: Trendelenburg’s
and a quiet environment for atleast 2 weeks. 50. Which precautions should be taken for a child with
37. The nurse reinforces instructions to the mother of a a platelet count of 18,000/mm3?
child diagnosed with pediculosis (head lice): Ans: use a soft bristled toothbrush
Permethrin has been prescribed. Which statement
by the mother regarding the use of the medication
Indicates a need for further teaching?
Ans: I need to shampoo my child’s hair, apply the
medication, leave it on for 10 minutes and then
rinse it out
38. Using an insect repellent when in the woods can
help prevent which of the following infection?
Ans: rocky mountain spotted fever
39. What is the first priority when initiating treatment
on a child with a major burn injury?
Ans: airway assessment
40. Which action is appropriate for the prevention of
diaper dermatitis?
Ans: wash diaper area with a mild soap and water
after each diaper change.
41. Which intervention would be included in a plan of
care for a child with Wilms tumor?
Ans: teach the child and family about nephrectomy
42. Which of the following antibodies is involved in
allergic reactions?
Ans: IgE
43. Which of the following assessment findings in a
client with leukemia would indicate that cancer has
invaded the brain?.
Ans: Headache and vomiting
44. Which of the following assessments of the skin of a
child is likely to reveal diaper dermatitis?
Ans: pruritus
45. Which of the following complications are three
main consequences of leukemia?
Ans: anemia, infection, and bleeding tendencies
46. Which of the following is not a classic triad clinical
manifestation of toxoplasmosis?
Ans: jaundice
47. Which of the following medications usually is given
to a client with leukemia as prophylaxis against P.
carinili pneumonia?
Ans: sulfamethoxazole and trimethoprim (Bactrim)
48. Which of the following represents the most
appropriate nursing interventions for a client with
pruritus caused by cancer or the treatments?
Ans: medicated cool baths