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minutes.
322. The nurse is performing an assessment on a 10-year-old child suspected to
have Hodgkin’s disease. Which assessment findings are specifically
characteristic of this disease? Select all that apply.
1. Abdominal pain

2. Fever and malaise

3. Anorexia and weight loss

4. Painful, enlarged inguinal lymph nodes
5. Painless, firm, and movable adenopathy in the cervical area

Answers

312. Answer: 1

Rationale: Colorless drainage on the dressing in a child after craniotomy indicates
the presence of cerebrospinal fluid and should be reported to the surgeon
immediately. Options 2, 3, and 4 are not the immediate nursing action because they
do not address the need for immediate intervention to prevent complications.
Test-Taking Strategy: Note the strategic word, immediately. Eliminate options 3
and 4 because they are comparable or alike and delay necessary intervention. Also,
note the words colorless drainage. This should alert you quickly to the possibility of
the presence of cerebrospinal fluid and direct you to the correct option.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Pediatrics: Oncological
Health Problem: Complex Care: Emergency Situations/Management
Priority Concepts: Clinical Judgment; Intracranial Regulation
Reference: Hockenberry, Wilson, Rodgers (2017), p. 834.

313. Answer: 4

Rationale: In the event of shock, the PHCP is notified immediately before the
nurse changes the child’s position or increases intravenous fluids. After craniotomy,
a child is never placed in the supine or Trendelenburg’s position because it increases
intracranial pressure (ICP) and the risk of bleeding. The head of the bed should be
elevated. Increasing intravenous fluids can cause an increase in ICP.
Test-Taking Strategy: Focus on the subject, care for the child following
craniotomy, and note the strategic words, most appropriate. Eliminate options 1 and 2
because these positions could increase ICP. Eliminate option 3 because increasing the
flow rate could also increase ICP. In addition, the nurse should not increase
intravenous fluids without a PHCP’s prescription.
Level of Cognitive Ability: Synthesizing

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