Author Question: What is the most appropriate nursing action when the nurse notes a reddened area on the forearm of a ... (Read 65 times)

tingc95 · **on:** Jun 27, 2018

What is the most appropriate nursing action when the nurse notes a reddened area on the forearm of a neutropenic child with leukemia?

a. Massage the area.
b. Turn the child more frequently.
c. Document the finding and continue to observe the area.
d. Notify the physician immediately.

Question 2

Which statement made by a nurse to the parents of a child with leukemia should be included in discharge instructions?

a. Your son's blood pressure must be taken daily while he is on chemotherapy..
b. Limit your son's fluid intake just in case he has central nervous system (CNS) involvement..
c. Your son must receive all of his immunizations in a timely manner..
d. Your son's temperature should be taken daily..

Mholman93 · **Reply #1 on:** Jun 27, 2018

Answer to Question 1

D
Any signs of infection in a child who is immunosuppressed must be reported immediately because it is considered a medical emergency. When a child is neutropenic, pus may not be produced and the only sign of infection may be redness. In a child with neutropenia, a reddened area may be the only sign of an infection. The area should never be massaged. The forearm is not a typical pressure area; therefore, the likelihood of the redness being related to pressure is very small. The observation should be documented, but because it may be a sign of an infection and immunosuppression, the physician must also be notified.

Answer to Question 2

D
An elevated temperature may be the only sign of an infection in an immunosuppressed child. Parents should be instructed to monitor their child's temperature daily because of the risk for infection, but it is not necessary to take a blood pressure daily. Fluid is never withheld as a precaution against increased intracranial pressure. If a child had confirmed CNS involvement with increased intracranial pressure, limiting fluid intake might be more appropriate. Children who are immunosuppressed should not receive any live virus vaccines.