A client with sickle cell disease is in a vaso-occlusive crisis and reporting a severe headache with blurry vision.
What intervention should the nurse perform first?
Administer analgesic medication.
Assess the client's neurological status.
Increase the client's intravenous fluids.
Administer 2 L of oxygen via nasal cannula.
The Correct Answer is B
Choice A rationale
While administering analgesics is a crucial step in managing a vaso-occlusive crisis due to severe pain, it is not the first intervention. The client's report of a severe headache with blurry vision, particularly in the context of sickle cell disease, is a sentinel symptom. These neurological signs can indicate a central nervous system complication, such as a stroke, which requires immediate neurological assessment before any other interventions.
Choice B rationale
In a vaso-occlusive crisis, a severe headache and blurry vision are neurological red flags. These symptoms suggest potential cerebral hypoxia or infarction, which could be a prelude to a stroke. Assessing the client's neurological status is the first priority to establish a baseline and determine the extent of the neurological deficit. This rapid assessment guides subsequent life-saving interventions.
Choice C rationale
Increasing intravenous fluids is a standard component of vaso-occlusive crisis management to promote hemodilution and improve blood flow. However, it is not the first action in this specific scenario. The client's presenting symptoms of headache and blurry vision point to a potential neurological emergency that requires immediate assessment to rule out or confirm a stroke, which takes precedence over general fluid management.
Choice D rationale
Administering oxygen is beneficial in a vaso-occlusive crisis to address tissue hypoxia. However, it is not the immediate first action given the client's specific neurological symptoms. Oxygen saturation is typically maintained above 95% in these patients. The priority is to assess the client's neurological status to rapidly identify a potentially life-threatening stroke, which dictates the immediate course of action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
This is a significant underestimation of a 2-3 year old's language skills. While a toddler can follow commands, their expressive language is also developing rapidly. They typically transition from single words to multi-word sentences and have a vocabulary of several hundred words. The lack of speech would be a cause for concern and would require further developmental evaluation.
Choice B rationale
This is the expected language skill level for a 2-3 year old toddler. At this stage, a toddler's vocabulary expands significantly, and they begin to combine words into simple sentences. This two-word stage, often called "telegraphic speech," is a key milestone and indicates the child is beginning to understand and apply grammatical rules.
Choice C rationale
This is an overestimation of a 2-3 year old's language skills. While their vocabulary is growing, their speech is not typically fully clear or understandable to all listeners. They may still mispronounce words or omit certain sounds. Full clarity of speech is usually not achieved until 4 or 5 years of age.
Choice D rationale
This is an overestimation of a 2-3 year old's vocabulary. The typical vocabulary for a 2-year-old is around 50 words, and by age 3, it may increase to around 200-300 words. A vocabulary of 800-900 words is more characteristic of a 4 to 5 year old and is not the expected norm for this age group.
Correct Answer is ["B","C","D","E"]
Explanation
Choice A rationale
Documenting a family history of allergies is important for a complete health history, but it is not a direct documentation of the patient's own reported allergies. The question asks what information to document regarding a patient's reported allergies, so the focus is on the patient's personal experience, not that of their family.
Choice B rationale
The type of allergic reaction is crucial information to document. This helps in distinguishing between a true anaphylactic reaction and a side effect or intolerance. Documenting the specific signs and symptoms, such as rash, hives, or shortness of breath, provides vital information for preventing future exposures and guiding appropriate treatment if one occurs.
Choice C rationale
The medication names are essential to document to prevent future exposure to the same drug. This ensures that the patient does not receive the offending medication again, which is a primary safety measure. It is a fundamental component of a complete allergy record to specify the substance that caused the reaction.
Choice D rationale
Documentation of Epi Pen use is critical as it indicates a severe, anaphylactic reaction requiring an emergency intervention. This information alerts providers to the high risk of a life-threatening allergic response and the need for preparedness, such as having epinephrine available for future exposure.
Choice E rationale
The date of the allergic reaction should be documented to provide a chronological history. This helps in understanding the timeline of the allergy and can be useful for determining if an allergy has changed over time or for correlating the reaction with a specific exposure
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