While performing an assessment of a patient who is ...

[lracut11]

While performing an assessment of a patient who is immunocompromised, the nurse notes the child to have thrush in the mouth, tenderness over the spleen upon palpation, and a white blood cell count of 3,000.
 
  Which nursing diagnoses will the nurse include in the care plan of this child based on these findings? Select all that apply.
 
  A) Ineffective protection
  B) Risk for imbalanced nutrition, less than body requirements
  C) Pain
  D) Impaired skin integrity
  E) Delayed growth and development

Question 2

The nurse is caring for an 8-year-old boy hospitalized for a bone marrow transplant. His parents are in and out of his room throughout the day. Which behaviors of the child would alert the nurse that he is in the second stage of separation anxiety?
 
  A) He ignores his parents when they return to his room.
  B) He cries uncontrollably whenever they leave.
  C) He forms superficial relationships with his caregivers.
  D) He sits quietly and is uninterested in playing and eating.

[Amiracle]

Answer to Question 1

Ans: A, B, C
Based on these symptoms the diagnosis of Ineffective protection is related to the decreased white blood cell count; Risk for imbalanced nutrition, less than body requirements, is related to the thrush; and Pain is related to the tenderness over the spleen and the thrush. There is no evidence to support the diagnoses of Impaired skin integrity or Delayed growth and development.

Answer to Question 2

Ans: D
Separation anxiety consists of three stagesprotest, despair, and detachment. In the protest stage, the child reacts aggressively to separation and exhibits great distress by crying, expressing agitation, and rejecting others who attempt to offer comfort. In the despair phase the child displays hopelessness by withdrawing from others, becoming quiet without crying, and exhibiting apathy, depression, lack of interest in play and food, and overall feelings of sadness. In the detachment stage the child shows interest in the environment, starts to play again, and forms superficial relationships with the nurses and other children. If the parents return, the child ignores them. A child in this phase of separation anxiety exhibits resignation, not contentment.

[lracut11]

TYSM

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