A child with leukemia is admitted for chemotherapy, and the nursing diagnosis 'altered nutrition, less than body requirements related to anorexia, nausea, and vomiting' is identified. Which intervention should the nurse include in this child's plan of care?

Correct Answer: B

Rationale: Allowing the child to eat any food desired and tolerated is the most appropriate intervention for a child with altered nutrition due to anorexia, nausea, and vomiting. It is crucial to prioritize maintaining adequate nutritional intake, and by allowing the child to choose foods they desire and can tolerate, the chances of improving their nutritional status increase. This approach helps in ensuring that the child receives necessary nutrients during chemotherapy, even if their appetite is affected by the treatment.

Correct Answer: C

Rationale: The primary goal of nursing care for a child diagnosed with rheumatic fever is to prevent cardiac damage. Rheumatic fever can lead to complications affecting the heart, making it crucial to monitor and prevent cardiac involvement to avoid long-term consequences. While addressing fever and joint pain are important aspects of care, preventing cardiac damage takes precedence in managing rheumatic fever.

Correct Answer: C

Rationale: In a situation where an infant with tetralogy of Fallot is acutely cyanotic and hyperpneic, the priority action should be to place the infant in a knee-chest position. This position helps increase systemic vascular resistance, improving pulmonary blood flow and subsequently ameliorating the cyanosis and hyperpnea. It is a non-invasive and effective intervention that can be promptly implemented by the nurse to address the immediate respiratory distress.

Correct Answer: B

Rationale: The correct answer is B) Palpate the anterior fontanel for tension and bulging. In a 3-month-old infant with a significant increase in frontal occipital circumference (FOC) and a large head-to-body size ratio, assessing the anterior fontanel is crucial to evaluate for signs of increased intracranial pressure. A tense or bulging fontanel could indicate abnormal brain growth or hydrocephalus, a serious condition requiring immediate medical attention. Option A) Measure the infant's head-to-toe length is not the most important action in this scenario as the concern is primarily related to the head circumference and signs of increased intracranial pressure, not overall body length. Option C) Observing the infant for sunken eyes is unrelated to the assessment of a large head size and would not provide relevant information in this situation. Option D) Plotting the measurement on the infant's growth chart is not the most immediate action needed when there are concerns about abnormal head growth and potential signs of increased intracranial pressure. It is important to address acute clinical signs first before considering long-term growth patterns. In a pediatric nursing context, understanding the significance of abnormal head growth and recognizing signs of increased intracranial pressure is critical for early detection and intervention in conditions like hydrocephalus. This scenario highlights the importance of thorough assessment skills and prompt action in pediatric care to ensure the well-being of infants.

Correct Answer: D

Rationale: In the context of pediatric nursing, particularly in caring for a teenager with sickle cell anemia, understanding dietary considerations is crucial. Choosing the correct drink on a hot day reflects this understanding. The correct choice, lemonade (Option D), is the best option because it is often recommended for individuals with sickle cell anemia due to its high vitamin C content, which can help reduce oxidative stress and inflammation associated with the disease. Milkshake (Option A) is high in dairy fat and sugar, which can contribute to weight gain and potentially exacerbate symptoms of sickle cell anemia. Iced tea (Option B) and diet cola (Option C) may contain caffeine, which can lead to dehydration, a concern for individuals with sickle cell anemia who are already at risk for dehydration due to increased water loss from sickling of red blood cells. Educationally, this question highlights the importance of nutrition in managing sickle cell anemia and reinforces the need for healthcare providers to educate patients and their families about making appropriate dietary choices to support their health. It also underscores the significance of understanding the specific needs and considerations for individuals with chronic conditions like sickle cell anemia.