Author Question: The nurse is caring for a child who has undergone stem cell transplantation for severe combined ... (Read 43 times)

geoffrey · **on:** Jun 27, 2018

The nurse is caring for a child who has undergone stem cell transplantation for severe combined immune deficiency. Which of the following would the nurse interpret as indicative of graft-versus-host disease?

A) Presence of wheezing
B) Splenomegaly
C) Maculopapular rash
D) Chronic or recurrent diarrhea

Question 2

The school nurse is walking through the lunchroom when one of the children says she feels strange after switching her lunch with her friend. Which assessment would be most important?

A) Asking if she has a rash anywhere
B) Checking if she has any nausea
C) Determining if her throat itches
D) Asking if she has abdominal pain

Ashley I · **Reply #1 on:** Jun 27, 2018

Answer to Question 1

C
Feedback:
The nurse should monitor the stem cell transplant child closely for a maculopapular rash that usually starts on the palms and soles for indication that graft-versus-host disease is developing. Wheezing and recurrent diarrhea are not typical clinical manifestations of graft-versus-host disease. Splenomegaly is associated with hypogammaglobulinem ia.

Answer to Question 2

C
Feedback:
Asking if the child's throat itches is most important because this aids in determining airway patency, which is always the priority. Asking about a rash, nausea, or abdominal pain can be done after the nurse is certain the child's airway is not jeopardized.