Page 937 - Saunders Comprehensive Review For NCLEX-RN

316. Answer: 1

Rationale: Leukemia is a malignant increase in the number of leukocytes, usually
at an immature stage, in the bone marrow. It affects the bone marrow, causing
anemia from decreased erythrocytes, infection from neutropenia, and bleeding from
decreased platelet production (thrombocytopenia). If a child is has a low platelet
3
9
count usually less than 50,000 mm (50.0 × 10 /L), bleeding precautions need to be
initiated because of the increased risk of bleeding or hemorrhage. Precautions
include limiting activity that could result in head injury, using soft toothbrushes,
checking urine and stools for blood, and administering stool softeners to prevent
straining with constipation. In addition, suppositories, enemas, and rectal
temperatures are avoided. Options 2, 3, and 4 are related to the prevention of
infection rather than bleeding.
Test-Taking Strategy: Note that the platelet count is low and recall that a low
platelet count places the child at risk for bleeding. In addition, note that options 2, 3,
and 4 are comparable or alike because they relate to prevention of and monitoring
for infection.
Level of Cognitive Ability: Analyzing
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process—Planning
Content Area: Pediatrics: Oncological
Health Problem: Pediatric-Specific: Cancers
Priority Concepts: Cellular Regulation; Clotting
Reference: McKinney et al. (2018), pp. 1152-1153.

317. Answer: 1

Rationale: The brain, although well protected by the solid bony cranium, is highly
susceptible to pressure that may accumulate within the enclosure. Volume and
pressure must remain constant within the brain. A change in the size of the brain,
such as occurs with edema or increased volume of intracranial blood or
cerebrospinal fluid without a compensatory change, leads to an increase in ICP,
which may be life-threatening. Vomiting, an early sign of increased ICP, can become
excessive as pressure builds up and stimulates the medulla in the brainstem, which
houses the vomiting center. Children with open fontanels (posterior fontanel closes
at 2 to 3 months; anterior fontanel closes at 12 to 18 months) compensate for ICP
changes by skull expansion and subsequent bulging fontanels. When the fontanels
have closed, nausea, excessive vomiting, diplopia, and headaches become
pronounced, with headaches becoming more prevalent in older children.
Test-Taking Strategy: Note the strategic word, early; focus on the age of the child,
and use age as the key to principles of growth and development. Knowing when the
fontanels close and focusing on the child’s age as 3 years eliminates options 2 and 3.
The subjective symptom of headache in option 4 is unreliable in a 3 year old, so
eliminate this option.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment

937