A nurse is caring for an 8-year-old male client in the emergency department (ED).
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.
The Correct Answer is []
Rationale for correct condition The client’s leg and abdominal pain following exertion and potential dehydration are classic triggers of sickle cell crisis, specifically a vaso-occlusive episode. Hemoglobin 7.6 g/dL and hematocrit 22% reflect anemia from sickled erythrocytes impairing oxygen delivery. Mucosal pallor and pain without respiratory distress or splenic signs further support vaso-occlusion rather than other complications. Elevated ferritin indicates chronic hemolysis and iron overload.
Rationale for correct actions IV fluids restore plasma volume, reducing blood viscosity and decreasing red cell sickling. Hydration improves microvascular perfusion and minimizes further occlusion. Blood transfusion increases oxygen-carrying capacity and reduces sickled hemoglobin percentage, alleviating tissue ischemia and systemic anemia. Transfusion also mitigates risk of organ damage by improving oxygenation.
Rationale for correct parameters Pain scale monitoring assesses therapy efficacy, crucial as pain is a primary symptom of vaso-occlusion. Frequent evaluation enables titration of analgesics and guides supportive interventions. Urine output reflects hydration status and renal perfusion—key concerns as hypovolemia and renal ischemia may occur in sickle cell crisis. Output <0.5 mL/kg/hr may signal renal compromise.
Rationale for incorrect conditions Acute chest syndrome presents with cough, hypoxia, and pulmonary infiltrates—absent in this client. Aplastic crisis shows extreme anemia without pain, often post-viral. Sequestration crisis involves sudden splenomegaly and hypovolemia, not evident in this case.
Rationale for incorrect actions Oxygen therapy isn’t necessary with SpO₂ at 98%; it doesn’t relieve vaso-occlusion. Ibuprofen is suboptimal for severe pain in sickle crisis. Warm compresses may assist pain but are not core interventions for systemic pathology.
Rationale for incorrect parameters Oxygen saturation is stable and not primary for vaso-occlusive monitoring. Spleen palpation assesses sequestration, irrelevant here. Temperature is modestly elevated but not the primary marker of crisis progression.
Take-home points • Sickle cell crisis manifests as severe pain from microvascular occlusion after dehydration or exertion • Treatment focuses on hydration and oxygen-carrying capacity via fluids and transfusion • Pain and urine output are direct indicators of response to vaso-occlusive management • Differentiating crisis types ensures targeted and effective care strategies
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}
Explanation
The following orders are expected: A, B, C, E. The following orders are unexpected: D.
Choice A rationale
An NPO status is an expected order for a client undergoing a procedure such as a major surgery, which necessitates an empty stomach to prevent aspiration during anesthesia. This order is a safety precaution to ensure the client’s respiratory tract is protected from gastric contents. This reduces the risk of aspiration pneumonia, a serious complication of anesthesia.
Choice B rationale
Bed rest is an expected order for clients with a medical condition that requires a reduction in physical activity to promote healing, conserve energy, or prevent complications. For example, a client with a cardiac condition, a client recovering from surgery, or a client with a high risk of falls would be ordered to remain on bed rest to minimize physiological stress.
Choice C rationale
A blood type and cross match is an expected order for a client who may require a blood transfusion. This is a critical safety step to ensure the blood to be transfused is compatible with the client’s blood, preventing a potentially fatal transfusion reaction. This test is routinely ordered prior to major surgeries or in cases of significant blood loss.
Choice D rationale
Cold compresses are generally unexpected for most systemic conditions unless a localized inflammation or injury is the primary issue. For example, cold compresses are used to reduce swelling and pain from sprains or burns, not typically for systemic conditions requiring other treatments. A systemic or internal issue does not respond well to localized cold application.
Choice E rationale
Morphine IV is an expected order for a client experiencing severe pain, such as post-operative pain or pain from a traumatic injury. Morphine is a powerful opioid analgesic that provides effective and rapid pain relief by binding to opioid receptors in the central nervous system. The IV route ensures a quick onset of action.
Correct Answer is D
Explanation
Choice A rationale
Asking the parents to leave the waiting room is not an appropriate action. Parental presence, especially for a young child, helps reduce anxiety and stress, which can positively impact the child's physiological response to surgery. The parents' presence provides comfort and security, which is essential for a positive perioperative experience and helps maintain the child's emotional stability.
Choice B rationale
Palpating the abdomen of a child with a Wilms tumor is contraindicated because this action can cause the tumor to rupture. A Wilms tumor is a nephroblastoma, which is a highly vascular and fragile malignancy of the kidney. A rupture could lead to the spillage of cancerous cells into the abdominal cavity, increasing the risk of metastasis and complicating the surgical procedure.
Choice C rationale
Discontinuing clear liquids 1 hour prior to surgery is incorrect and poses a risk for aspiration. The typical NPO (nothing by mouth) guideline for clear liquids is at least 2 hours before the procedure for a child to ensure adequate gastric emptying. This reduces the risk of vomiting and aspiration during induction of anesthesia, which could lead to severe pulmonary complications such as aspiration pneumonia.
Choice D rationale
Monitoring the child's blood pressure continuously is an important action because hypertension is a common clinical manifestation of Wilms tumor. The tumor can secrete renin, leading to increased blood pressure. Continuous monitoring allows for early detection of significant changes, which may require medical intervention to stabilize the child's condition before and during surgery.
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