A nurse is caring for a child who has sickle cell anemia. Which of the following findings is the priority for the nurse to report to the provider?
Kyphosis
Constipation
Enuresis
Facial twitching
The Correct Answer is D
A) Kyphosis, or curvature of the spine, is not typically an urgent concern in sickle cell anemia.
B) Constipation can occur but is not typically an urgent complication.
C) Enuresis, or bedwetting, may be a concern but is not typically an urgent complication.
D) Facial twitching could indicate neurological involvement or a stroke, which is a serious complication of sickle cell anemia and requires immediate attention.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Providing the child with a warm blanket can help keep the child comfortable during the course of the illness but initiating airborne precautions is best intervention required.
B. Assessing the oral cavity for Koplik spots is not relevant for varicella, as Koplik spots are associated with measles.
C. Administering aspirin for fever is contraindicated in children with varicella due to the risk of Reye's syndrome.
D. The nurse should initiate airborne precautions, which include placing the child in a private room with negative air pressure, wearing a mask or respirator when entering the room, and limiting visitors and staff exposure. Airborne precautions prevent the transmission of varicella through small droplets that can remain suspended in the air for long periods of time.
Correct Answer is A
Explanation
A) Tachypnea is a sign of respiratory distress and may indicate hypoxia, dehydration, or increased work of breathing. The nurse should report this finding to the provider and monitor the infant's oxygen saturation, heart rate, and respiratory rate.
B) Coughing is a common symptom of RSV and may not require immediate reporting unless severe.
C) Rhinorrhea (runny nose) is a common symptom of RSV and may not require immediate reporting unless severe.
D) Pharyngitis (sore throat) is a common symptom of RSV but is not as urgent as tachypnea.
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