A nurse is creating a plan of care for a child who has acute lymphoid leukemia and an absolute neutrophil count of 400/mm³ (2500 to 8000/mm³). Which of the following interventions should the nurse include in the plan?
Encourage friends and family to visit the child.
Provide a low-protein diet for the child.
Collect a daily urine specimen from the child to check for proteinuria.
Withhold administering the varicella vaccine to the child.
The Correct Answer is D
Rationale:
A. Encouraging friends and family to visit the child is not appropriate due to the risk of infections, as the child has a severely compromised immune system.
B. A low-protein diet is not indicated; children with leukemia often require adequate nutrition to support their health.
C. Collecting a daily urine specimen for proteinuria is not specifically indicated for this condition; the focus should be on infection prevention.
D. Withholding the varicella vaccine is essential because live vaccines are contraindicated in immunocompromised patients due to the risk of severe infections.
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Correct Answer is B
Explanation
Rationale:
A. While offering choices can promote autonomy, allowing clients to choose their own mealtimes may lead to avoidance of meals and is not a structured approach needed for clients with anorexia nervosa.
B. Supervision during and after eating is critical in managing clients with anorexia nervosa to ensure they consume the necessary nutrients and to monitor for any harmful behaviors, such as purging.
C. Although providing choices can support autonomy, it may not be suitable for clients with anorexia nervosa, as they might choose low-calorie or unhealthy options.
D. Encouraging casual conversation about food can sometimes increase anxiety or lead to fixation on eating behaviors, making it an inappropriate strategy for this population.
Correct Answer is B
Explanation
Rationale:
A. Hypotension is not a common adverse effect of estradiol; instead, it may cause hypertension.
B. Bruising can indicate thrombocytopenia or other clotting issues, which are serious adverse effects of estradiol and should be reported immediately.
C. Headaches are a common side effect of estradiol but are usually not severe; they typically do not require reporting unless they are persistent or severe.
D. Oliguria is not a known adverse effect of estradiol and may indicate other underlying issues that are unrelated to this medication.