Page 934 - Saunders Comprehensive Review For NCLEX-RN

4. Initiate protective isolation precautions.
317. The nurse is monitoring a 3-year-old child for signs and symptoms of
increased intracranial pressure (ICP) after a craniotomy. The nurse plans to
monitor for which early sign or symptom of increased ICP?
1. Vomiting
2. Bulging anterior fontanel
3. Increasing head circumference
4. Complaints of a frontal headache
318. 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 performed
because acute lymphocytic leukemia is suspected. The nurse determines that
which laboratory result confirms the diagnosis?
1. Lumbar puncture showing no blast cells
2. Bone marrow biopsy showing blast cells
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3. Platelet count of 350,000 mm (350 × 10 /L)
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4. White blood cell count 4500 mm (4.5 × 10 /L)
319. A 6-year-old child with leukemia is hospitalized and is receiving
combination chemotherapy. Laboratory results indicate that the child is
neutropenic, and protective isolation procedures are initiated. The
grandmother of the child visits and brings a fresh bouquet of flowers picked
from her garden and asks the nurse for a vase for the flowers. Which
response should the nurse provide to the grandmother?
1. “I have a vase in the utility room, and I will get it for you.”
2. “I will get the vase and wash it well before you put the flowers in
it.”
3. “The flowers from your garden are beautiful, but should not be
placed in the child’s room at this time.”
4. “When you bring the flowers into the room, place them on the
bedside stand as far away from the child as possible.”
320. A diagnosis of Hodgkin’s disease is suspected in a 12-year-old child. Several
diagnostic studies are performed to determine the presence of this disease.
Which diagnostic test result will confirm the diagnosis of Hodgkin’s disease?
1. Elevated vanillylmandelic acid urinary levels
2. The presence of blast cells in the bone marrow
3. The presence of Epstein-Barr virus in the blood
4. The presence of Reed-Sternberg cells in the lymph nodes
321. Which specific nursing interventions are implemented in the care of a child
with leukemia who is at risk for infection? Select all that apply.
1. Maintain the child in a semiprivate room.

2. Reduce exposure to environmental organisms.

3. Use strict aseptic technique for all procedures.

4. Ensure that anyone entering the child’s room wears a mask.

5. Apply firm pressure to a needle-stick area for at least 10

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