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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer and explanation is:
c. Denial
The nurse should identify that the client is experiencing the stage of denial in the grief process. Denial is a common psychological defense mechanism that individuals may exhibit when faced with a stressful or overwhelming situation, such as the prospect of open heart surgery. It involves a refusal to accept or acknowledge the reality of the situation. In this case, the client's statement of being confident to go home shortly after surgery demonstrates a denial of the potential challenges and recovery process associated with such a procedure.
Explanation for the other options:
A . Anger: Anger is a stage of grief characterized by feelings of resentment, frustration, and hostility. It is common for individuals to experience anger as part of the grief process, but the client's statement does not indicate anger.
B. Depression: Depression is another stage of grief marked by feelings of sadness, hopelessness, and loss. While it is normal for individuals to experience some level of anxiety or sadness before undergoing surgery, the client's statement does not specifically reflect depression.
d. Acceptance: Acceptance is the final stage of grief, where individuals come to terms with their situation and find a sense of peace or resolution. The client's statement indicates a lack of acceptance as they are denying the potential impact of the surgery and its recovery process.
Correct Answer is C
Explanation
c. Ketones positive.
Explanation:
Ketones in the urine can be an indication of diabetic ketoacidosis (DKA) or other metabolic disorders. It is abnormal and should be reported to the healthcare provider for further evaluation and management. Positive ketones suggest that the body is breaking down fats for energy instead of using glucose, which can be a sign of inadequate insulin levels or utilization.
Options a, b, and d are within normal ranges or do not indicate an immediate concern. A specific gravity of 1.020 is within the normal range and indicates appropriate urine concentration. Uric acid levels of 475 mg/24 hr are not mentioned as abnormal or concerning in the context provided. Nitrites negative indicates the absence of nitrites in the urine, which is a normal finding and indicates the absence of a urinary tract infection.
However, it's important to note that clinical judgment should always be exercised, and the nurse should consider the patient's overall clinical presentation and history when interpreting laboratory results and making decisions regarding reporting to the provider.
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