Answer to Question 1
1
Rationale 1: When the child is thrombocytopenic (decreased platelets) from chemotherapy, the nurse should not administer IM injections because of the risk of bleeding.
Rationale 2: Intake and output should be measured for all children receiving chemotherapy but not due to the thrombocytopenia.
Rationale 3: Gentle palpation should still be included in physical assessments unless a Wilms' tumor has been diagnosed or is suspected. However, it is not related to the thrombocytopenia.
Rationale 4: Oral hygiene care should be done with a soft toothbrush.
Global
Answer to Question 2
4
Rationale 1: The questions asked in the stem are not classified as disease surveillance questions; they are developmental surveillance questions.
Rationale 2: While health promotion and maintenance activities are related to developmental surveillance, these questions are looking specifically at the milestones; therefore, the answers health promotion and health maintenance are incorrect.
Rationale 3: While health promotion and maintenance activities are related to developmental surveillance, these questions are looking specifically at the milestones; therefore, the answers health promotion and health maintenance are incorrect.
Rationale 4: The questions asked by the nurse are seeking information about developmental milestones; therefore, the nurse is involved in developmental surveillance.
Global Rationale: