A nurse is contributing to the plan of care for an adolescent client who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following interventions should the nurse include in the plan?
Decrease daily oral fluid intake.
Maintain bed rest to prevent hypoxemia.
Apply cold compresses to painful joints.
Administer meperidine to eliminate a fever.
The Correct Answer is B
Choice A rationale:
Decrease daily oral fluid intake. Rationale: This choice is not appropriate for a client experiencing a vaso-occlusive crisis in sickle cell anemia. In this crisis, there is a risk of dehydration due to increased fluid loss, and decreasing oral fluid intake would exacerbate this issue. Adequate hydration is important to prevent further sickling of red blood cells and maintain organ perfusion.
Choice B rationale:
Maintain bed rest to prevent hypoxemia. Rationale: This is the correct choice. During a vaso-occlusive crisis in sickle cell anemia, blood flow to certain tissues is restricted, leading to tissue hypoxia and pain. Bed rest is recommended to reduce metabolic demands and oxygen consumption, helping to prevent further tissue damage and improve oxygenation. It also reduces the risk of complications such as thrombosis and respiratory compromise.
Choice C rationale:
Apply cold compresses to painful joints. Rationale: Applying cold compresses is not a recommended intervention for vaso-occlusive crisis in sickle cell anemia. Cold can exacerbate vasoconstriction and further compromise blood flow to the affected tissues. Warm compresses or warm baths might be more appropriate to promote vasodilation and alleviate pain.
Choice D rationale:
Administer meperidine to eliminate a fever. Rationale: Administering meperidine solely to eliminate a fever is not the primary focus of care for a vaso-occlusive crisis. The priority is to manage pain and improve tissue perfusion. Meperidine is an opioid analgesic that can be used to manage severe pain associated with sickle cell crises, but it should be given with caution due to the risk of respiratory depression and the potential for addiction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D"]
Explanation
Choice A rationale:
Allowing an adolescent driver to answer their phone while driving can lead to distraction, increasing the risk of accidents. Engaging in conversations on the phone diverts the driver's attention from the road, which is unsafe. It's crucial for drivers, especially new ones, to focus solely on driving to prevent accidents.
Choice B rationale:
This choice is correct. Not answering the phone while driving is a responsible behavior that indicates an understanding of the dangers of distracted driving. Parents should encourage their children to focus on the road and avoid distractions like phone calls, promoting safe driving practices.
Choice C rationale:
This statement is incorrect. Adolescents should continue wearing helmets when riding their bikes even after age 13. Wearing helmets helps prevent head injuries in case of accidents. While older adolescents might perceive themselves as less prone to accidents, they are still at risk, and helmets are essential for their safety.
Choice D rationale:
This choice is correct. Wearing appropriate protective clothing, like long pants, while driving an all-terrain vehicle (ATV) is crucial. Long pants can provide some degree of protection against scrapes, scratches, and minor injuries that can occur while operating an ATV. It's a safety measure that shows an understanding of the importance of protective gear.
Correct Answer is B
Explanation
Choice A rationale:
"Provide your child with long-term goals to increase self-esteem." While setting long-term goals can indeed contribute to increasing a child's self-esteem, this choice may not be the most directly related to promoting a child's learning, especially for a child with attention deficit hyperactivity disorder (ADHD). Children with ADHD often struggle with attention and focus, and setting long-term goals might not address their immediate needs in terms of learning strategies.
Choice B rationale:
"Offer your child frequent breaks in activity during the day." Children with ADHD often benefit from frequent breaks in activities to help manage their attention and energy levels. These breaks can help prevent mental fatigue, increase focus, and enhance overall learning. This choice is appropriate for promoting the child's learning and is often recommended as part of ADHD management strategies.
Choice C rationale:
"Administer your child's medication at bedtime to prevent insomnia." This statement is not necessarily accurate for all medications used to treat ADHD. Some ADHD medications can indeed cause insomnia as a side effect, but the timing of medication administration can vary based on the specific medication and the child's individual response. It's essential for parents to follow the healthcare provider's instructions regarding medication timing.
Choice D rationale:
"Schedule a different routine for your child each day." Children with ADHD often benefit from consistent routines and schedules, as they provide structure and predictability, which can help manage their symptoms. Introducing a different routine each day could actually exacerbate symptoms and make it more challenging for the child to focus and engage in learning activities.
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