A nurse is contributing to the plan of care for a school-age child who has sickle-cell disease and is experiencing a vaso-occlusive crisis. Which of the following should the nurse recommend to include in the plan of care?

Limit ﬂuid intake during the evening

Perform passive range-of-motion exercises.

Apply cold compresses to painful areas.

Provide a low-protein diet

Answer and Explanation

The Correct Answer is B

b. Perform passive range-of-motion exercises.

During a vaso-occlusive crisis in sickle-cell disease, blood ﬂow to certain areas of the body may be restricted, leading to pain and tissue damage. Passive range-of-motion exercises can help promote blood circulation and prevent joint stiﬀness and further complications. These exercises involve gently moving the child's joints through their full range of motion without active participation from the child.

Explanation for the other options:

a. Limit ﬂuid intake during the evening: Fluid intake is important in sickle-cell disease to prevent dehydration and maintain adequate blood ﬂow. Restricting ﬂuid intake during a vaso-occlusive crisis can further contribute to dehydration and may worsen the crisis. It is important to encourage ﬂuid intake unless otherwise instructed by the healthcare provider.

c. Apply cold compresses to painful areas: Cold compresses are not recommended during a vaso-occlusive crisis in sickle-cell disease. Cold temperatures can cause vasoconstriction and further worsen the blood ﬂow to aﬀected areas, leading to increased pain and tissue damage. Warm compresses or warm packs may be used to promote vasodilation and provide pain relief.

d. Provide a low-protein diet: A low-protein diet is not specifically indicated in the plan of care for a vaso- occlusive crisis in sickle-cell disease. Adequate protein intake is important for overall nutritional needs and tissue repair. The focus of nutritional management in sickle-cell disease is usually on a well-balanced diet that includes adequate hydration and appropriate nutrient intake.

In summary, performing passive range-of-motion exercises is an appropriate intervention to include in the

plan of care for a school-age child experiencing a vaso-occlusive crisis in sickle-cell disease.

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Correct Answer is D

Explanation

Choice A:

An absent dorsal pedal pulse would indicate a vascular problem such as arterial occlusion, not a deep vein thrombosis (DVT). In the case of DVT, blood flow in the veins is obstructed, but the arterial pulse, which is related to arterial circulation, should remain intact unless there is a separate arterial issue. Therefore, absent pulses are not characteristic of DVT.

Choice B:

Shiny, hairless skin is a sign typically associated with chronic arterial insufficiency, not DVT. This skin change occurs when there is poor arterial blood flow, which leads to a lack of nourishment for the skin, causing it to become thin and shiny. In contrast, DVT affects the veins and does not usually cause these skin changes in the acute phase.

Choice C:

Irregular, bulging veins are indicative of varicose veins or chronic venous insufficiency, not a DVT. Varicose veins occur when the veins become swollen and twisted due to weak or damaged valves. DVT, on the other hand, involves the formation of a clot in the deep veins and does not typically cause the veins to bulge visibly, especially in the early stages.

Choice D:

Dull, aching pain is a common symptom associated with deep vein thrombosis. This pain typically occurs in the affected extremity and is often described as a constant, aching sensation. The pain can worsen with movement or standing and is due to the inflammation and obstruction caused by the blood clot in the deep veins. This is a hallmark sign of DVT, along with swelling and redness in the affected limb.

A. Sims B. Prone C. Supine D. Orthopneic

Correct Answer is C

Explanation

When instructing a client on self-administration of nasal drops, the nurse should recommend the supine position. In the supine position, the client lies on their back with the head slightly elevated. This position allows for easy access to the nostrils and facilitates the proper instillation of the nasal drops.

The other options are not recommended for instillation of nasal drops for various reasons:

a) Sims position: Simsposition is a side-lying position with the upper leg ﬂexed. This position is often used for rectal examinations or procedures and is not suitable for instilling nasal drops.

b) Prone position: Prone position refers to lying face down. It is not ideal for administering nasal drops as it

can obstruct proper access to the nostrils and make it difficult to instill the drops accurately.

d) Orthopneic position: Orthopneic position is a sitting position with the upper body supported by pillows. It is commonly used by individuals with respiratory distress to facilitate breathing. However, it is not specifically recommended for administering nasal drops as it may not provide optimal access to the nostrils for proper instillation.

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A nurse is contributing to the plan of care for a school-age child who has sickle-cell disease and is experiencing a vaso-occlusive crisis. Which of the following should the nurse recommend to include in the plan of care?

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