Which of the following blood study results would the nurse expect as most likely when caring for the child with iron deficiency anemia?

Correct Answer: C

Rationale: Iron deficiency anemia is characterized by a decreased mean corpuscular volume (MCV) due to the microcytic red blood cells that result from inadequate iron availability for hemoglobin synthesis. This leads to smaller red blood cells, which are reflected in a decreased MCV. Iron deficiency anemia would not typically result in an increased hemoglobin or normal hematocrit since the lack of iron impairs the production of red blood cells. Additionally, the total iron-binding capacity (TIBC) would usually be increased in iron deficiency anemia as the body attempts to compensate for the decreased iron levels by increasing its ability to bind and transport iron. Therefore, the nurse would expect a decreased mean corpuscular volume (MCV) in a child with iron deficiency anemia.

Correct Answer: C

Rationale: Option C, which is to toilet the patient according to his pre-illness schedule, whether or not he feels the urge, is the best intervention by the nurse to help reduce episodes of bowel incontinence in this patient with subarachnoid hemorrhage. This strategy can help establish a routine and promote regular bowel movements, which may reduce the likelihood of bowel incontinence episodes. Asking the patient frequently if he has to have a bowel movement (Option A) may not be effective, as the patient may not always be able to accurately communicate their needs due to the underlying condition. Placing incontinence pads on the patient's bed and chair (Option B) may manage the consequences of incontinence but does not address the root cause. While taking care not to embarrass the patient when incontinent episodes occur (Option D) is important for maintaining the patient's dignity, it does not directly address the issue of reducing bowel incontinence episodes.

Correct Answer: C

Rationale: When caring for a child with Cushing's syndrome, it is important to monitor weight each day and report any weight loss. Cushing's syndrome is characterized by a metabolic disorder that can lead to weight gain, particularly in the abdominal area. However, sudden weight loss in a child with Cushing's syndrome can be a sign of worsening condition or inadequate treatment. Therefore, monitoring weight regularly is crucial in managing the child's condition and adjusting the treatment plan accordingly.

Correct Answer: A

Rationale: Monitoring head circumference is essential in children with meningitis to assess for possible development of hydrocephalus. Hydrocephalus is a potentially serious complication that can occur following meningitis. An increase in head circumference can indicate the accumulation of cerebrospinal fluid in the brain due to hydrocephalus. Regularly measuring the head circumference allows healthcare providers to detect any early signs of hydrocephalus and take appropriate actions such as further imaging or intervention. Monitoring for convulsions, assessing pupil size, and watching for vomiting are important aspects of care for a child with meningitis but are not specific to monitoring for hydrocephalus.

Correct Answer: B

Rationale: House rules are negotiated: In maintaining therapeutic nurse-family boundaries, it is important for the nurse to establish clear and appropriate boundaries by involving the family in negotiating house rules. This helps to define roles and responsibilities, promoting mutual respect and understanding between the nurse and the family. By negotiating house rules, the nurse can create a structured environment that supports the well-being of the family.

Correct Answer: A

Rationale: For J.E., who suffered head injuries in a motor vehicle accident, appropriate nursing interventions should focus on holistic care to prevent complications and promote recovery. Option A includes skin care and position changes every 2 hours (q2h) and as needed, which is crucial for preventing pressure injuries in the immobile patient. Maintaining alignment of extremities helps prevent muscle contractures. Respiratory exercises are essential for preventing atelectasis and improving lung function in patients at risk for pneumonia due to decreased mobility. These interventions address the immediate needs of the patient and aim to prevent further complications related to immobility and head injury. Options B, C, and D lack the comprehensive approach to care provided in option A, making it the most appropriate choice for J.E.

Correct Answer: C

Rationale: Cisplatin is a cornerstone in the treatment of germ cell tumors.

Correct Answer: C

Rationale: Unintentional injuries are the major cause of death for children older than 1 year. These include accidents such as drownings, car accidents, fires, falls, and poisoning. Children are curious and naturally explore their environment, which can put them at risk for accidents. It is important for parents and caregivers to create safe environments for children, supervise them closely, and take appropriate safety precautions to prevent these injuries. By being mindful of potential hazards and actively working to prevent accidents, we can help reduce the incidence of unintentional injuries and protect children's well-being.

Correct Answer: B

Rationale: Neurofibromatosis type 1 is strongly associated with an increased risk of developing optic gliomas.