Author Question: The nurse is caring for a 7-year-old boy whose left leg is immobilized. What is the priority nursing ... (Read 89 times)

fnuegbu · **on:** Jun 27, 2018

The nurse is caring for a 7-year-old boy whose left leg is immobilized. What is the priority nursing intervention?

A) Enlist the assistance of a child life specialist.
B) Explain to the boy that he must keep his leg very still.
C) Apply a clove hitch restraint to the boy's left leg.
D) Explain that a restraint will be applied if he cannot hold still.

Question 2

The nurse is caring for a 5-year-old boy undergoing radiation treatment for a neuroblastoma. Which of the following nursing diagnoses would be most appropriate?

A) Activity intolerance related to anemia and weakness
B) Impaired skin integrity related to desquamation from cellular destruction
C) Impaired oral mucosa related to the presence of oral lesions
D) Malnutrition and anorexia related to nausea and vomiting

jesse.fleming · **Reply #1 on:** Jun 27, 2018

Answer to Question 1

B
Response:
An explanation about the goal is necessary and appropriate for a 7-year-old child so he can understand what is required. In many cases, this will be all that is needed. Explaining that a restraint will be applied if the boy cannot hold still will likely be perceived as a threat or punishment. All alternative measures need to be tried before restraints are used. Enlisting the assistance of the child life specialist is not a priority.

Answer to Question 2

B
Response:
A nursing diagnosis of impaired skin integrity evidenced by desquamation of the radiation site would be made only for a child undergoing radiation therapy. Activity intolerance due to anemia and weakness, impaired oral mucosa evidenced by oral lesions, and malnutrition and anorexia due to nausea and vomiting are diagnoses common to both radiation and chemotherapy.