An 8-year-old child had a hematopoietic stem cell transplant 10 months ago. The father brings her to the clinic, where the child reports "I just don't feel well." Dad relates that the child has been lethargic and sleeping a lot
The child's vital signs are within normal range for age. What action by the nurse is best?
A.
Explain that growth spurts can cause fatigue.
B.
Prepare the family for a "fever" workup.
C.
Provide reassurance to the father and child.
D.
Review side effects of immunosuppressants.
ANS: B
After a stem cell transplant, patients are on lifelong immunosuppressant therapy. These patients may contract illnesses, especially infections, without showing the classic signs and symptoms. The nurse should assume the child has an infection and prepare the child and father for a full workup to determine the origins of the infection. Reassurance is always an important nursing intervention, but does not take priority over the child's physical health. At each clinic visit, the nurse should review the treatment regimen, including side effects of medications, but again this is not the priority. Until proven otherwise, this child is ill, and not just having a growth spurt.
You might also like to view...
The staff educator in the ICU is talking with a group of new nurses about osmotic diuretics. The educator would tell the new nurses that osmotic diuretics act on which site in the nephron?
A) Proximal tubule B) Glomerulus C) Ascending limb of loop of Henle D) Collecting tubule
Stage 1 hypertension with no cardiovascular risks is treated with lifestyle modifications
Indicate whether the statement is true or false.
The nurse is providing education regarding early detection of breast cancer to a group of women between the ages of 30 and 40
According to recommendations from the American Cancer Society, the nurse should explain that it is important for these women to 1. do monthly breast self-exams. 2. have a yearly mammogram. 3. see a physician if there is a strong family history of breast cancer. 4. have an annual breast exam performed by a health care provider.
A nurse is planning care for a child with hyponatremia. The nurse, delegating care of this child to a licensed vocational nurse (LVN), cautions the LVN to immediately report which clinical manifestation?
1. Seizures 2. Respiratory distress 3. Hyperthermia 4. Bradycardia