A nurse is developing a plan of care for an adolescent who is experiencing a vaso-occlusive crisis. The adolescent reports painful joints, a fever, and abdominal pain. Which of the following interventions should the nurse include in the plan?
Administer antispasmodics.
Apply ice to joints.
Initiate IV fluids.
Assess for hyperkalemia.
The Correct Answer is C
A. Administer antispasmodics: Antispasmodics are not typically used for vaso-occlusive crisis pain, which is usually due to ischemia and not muscle spasms.
B. Apply ice to joints: Applying ice is not recommended as it can cause vasoconstriction, worsening the sickling of cells and the pain associated with a vaso-occlusive crisis. Heat application is more appropriate to promote circulation.
C. Initiate IV fluids: Correct. Hydration is a key intervention in managing a vaso-occlusive crisis because it helps to decrease the viscosity of the blood and prevent further sickling of cells.
D. Assess for hyperkalaemia: While it is important to monitor electrolyte levels, hyperkalaemia is not directly associated with a vaso-occlusive crisis. The primary focus should be on pain management and hydration.
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Related Questions
Correct Answer is D
Explanation
A. Double vision: Double vision is not a common complication of a lumbar puncture. Complications typically involve symptoms related to cerebrospinal fluid (CSF) leakage or infection.
B. Nuchal rigidity when standing: Nuchal rigidity (stiff neck) can indicate meningitis, but it is not specifically a complication of a lumbar puncture. Nuchal rigidity is more likely to be associated with an underlying condition that prompted the lumbar puncture rather than the procedure itself.
C. Pain in the posterior iliac crest: Pain at the posterior iliac crest is not typical after a lumbar puncture, as the procedure is performed in the lower back at the lumbar spine region.
D. Headache: Headache is a common complication following a lumbar puncture, often due to a CSF leak. The headache typically worsens when the patient is in an upright position and improves when lying down.
Correct Answer is B
Explanation
A. Weight loss of 5%: A 5% weight loss is typically indicative of mild to moderate dehydration, not severe.
B. Sunken anterior fontanelle: A sunken anterior fontanel is a sign of severe dehydration in infants as it indicates significant fluid loss.
C. Produces tears when crying: Producing tears is a sign of adequate hydration. Absence of tears would be more concerning for dehydration.
D. Capillary refill time 3 seconds: A capillary refill time of 3 seconds is at the upper limit of normal for infants. In severe dehydration, capillary refill time would typically be longer than 3 seconds.
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