A nurse is planning care for a child who is experiencing a sickle cell crisis.
Which of the following interventions should the nurse include in the plan of care?
Administer meperidine as needed for plan
Initiate bed rest
Limit fluid intake
Apply cold compresses to affected joints
The Correct Answer is B
Choice A rationale
Meperidine is not the first choice for pain management in sickle cell crisis due to its potential to cause seizures and other side effects.
Choice B rationale
Bed rest is recommended during a sickle cell crisis to decrease the body’s demand for oxygen, reduce the workload of the heart, and improve blood flow.
Choice C rationale
Limiting fluid intake is not recommended during a sickle cell crisis. Adequate hydration is important to prevent further sickling of cells and to maintain kidney function.
Choice D rationale
Cold compresses can cause vasoconstriction and may exacerbate the crisis. Warm compresses are usually recommended to increase blood flow and reduce pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choiceB.
Choice A rationale:
Dark brown blood in emesis is typically old blood and may not require immediate intervention.However, it should still be monitored and reported to the healthcare provider.
Choice B rationale:
Frequent swallowing can indicate active bleeding from the surgical site, which requires immediate intervention.This is a sign that the child may be swallowing blood, which can lead to significant blood loss.
Choice C rationale:
An axillary temperature of 38°C (100°F) is a mild fever and not uncommon postoperatively.It should be monitored, but it does not require immediate intervention.
Choice D rationale:
A pain level of 5 on the FACES scale indicates moderate pain, which is expected after a tonsillectomy.Pain management should be addressed, but it does not require immediate intervention.
Correct Answer is D
Explanation
Choice A rationale
A toddler repeatedly refusing to let a nurse auscultate his lungs is not necessarily an indicator of child abuse. It could be due to fear, discomfort, or lack of understanding about the procedure.
Choice B rationale
An 8-month-old infant crying when his parents leave the room is a normal developmental behavior known as separation anxiety, and it is not an indicator of child abuse.
Choice C rationale
A mother hesitating to comfort her 6-month-old infant could be due to various reasons, including stress, depression, or lack of knowledge about infant care. While it could potentially be a sign of neglect, it is not a definitive indicator of child abuse.
Choice D rationale
A toddler having bruises on his knees is a common occurrence due to their active nature and frequent falls. However, if the bruises are frequent, unexplained, or have distinct patterns, they could be potential indicators of child abuse.
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