A nurse is caring for a group of clients on a pediatric unit.
Which of the following clients is most at risk for insufficient vascular perfusion?
An adolescent who has a urinary tract infection.
A toddler who is receiving intravenous fluids.
A preschooler who has otitis media.
A school-age child who is in a spica cast.
The Correct Answer is D
The correct answer is D. A school-age child who is in a spica cast.
Choice A rationale
An adolescent with a urinary tract infection (UTI) is not at high risk for insufficient vascular perfusion. UTIs primarily affect the urinary system and do not typically impact vascular perfusion.
Choice B rationale
A toddler receiving intravenous fluids is not at high risk for insufficient vascular perfusion. IV fluids help maintain hydration and vascular volume, supporting adequate perfusion.
Choice C rationale
A preschooler with otitis media (ear infection) is not at high risk for insufficient vascular perfusion. Otitis media affects the middle ear and does not typically impact vascular perfusion.
Choice D rationale
A school-age child in a spica cast is at high risk for insufficient vascular perfusion. The cast can restrict blood flow, leading to complications such as compartment syndrome, which requires immediate medical attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","E","F","G","H"]
Explanation
Choice A rationale: Applying cold compresses to the affected joints is not recommended for vaso-occlusive crises in sickle cell disease. Cold can cause vasoconstriction, which may worsen the pain and decrease blood flow to the affected areas. Warm compresses are preferred to promote vasodilation and improve blood flow.
Choice B rationale: Administering meperidine IV for pain is not recommended due to the risk of neurotoxicity and the potential for seizures with repeated use. Other opioids, such as morphine or hydromorphone, are preferred for managing severe pain in vaso-occlusive crises.
Choice C rationale: Administering folic acid as prescribed is important for clients with sickle cell disease. Folic acid helps in the production of new red blood cells, which is crucial for individuals with sickle cell disease who experience chronic hemolysis and anemia.
Choice D rationale: Restricting oral intake is not necessary for a client with a vaso-occlusive crisis unless there are specific medical indications. Adequate hydration is essential to help reduce the viscosity of the blood and prevent further sickling of red blood cells.
Choice E rationale: Giving oral hydroxyurea is important for managing sickle cell disease. Hydroxyurea helps to increase the production of fetal hemoglobin, which reduces the frequency and severity of vaso-occlusive crises. It is a key medication in the long-term management of sickle cell disease.
Choice F rationale: Monitoring oxygen saturation continuously is important to ensure that the client is receiving adequate oxygenation. Hypoxia can exacerbate sickling of red blood cells and worsen the vaso-occlusive crisis. Continuous monitoring allows for prompt intervention if oxygen levels drop.
Choice G rationale: Placing the client on strict bed rest is important to reduce metabolic demands and prevent further pain and complications. Rest helps to conserve energy and reduce the risk of additional stress on the body during a vaso- occlusive crisis.
Choice H rationale: Instructing the parent to ensure the pneumococcal vaccine is current is important for preventing infections. Clients with sickle cell disease are at increased risk for infections, particularly with encapsulated bacteria like Streptococcus pneumoniae. Keeping vaccinations up to date is crucial for reducing the risk of serious infections.
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale
Koplik spots are small, bluish-white spots with a red halo that appear inside the cheeks and are a characteristic sign of measles.
Choice B rationale
Koplik spots do not appear on the tongue.
Choice C rationale
Koplik spots do not appear on the gums.
Choice D rationale
Koplik spots do not appear inside the lips.
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