A nurse is planning care for an adolescent client who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following interventions is the nurse's priority?
Applying heat to the affected areas
Administering prophylactic antibiotics
Administering the pneumococcal vaccine
Promoting bed rest
The Correct Answer is D
A. Applying heat to the affected areas: In vaso-occlusive crises associated with sickle cell disease, heat packs can be a helpful part of pain management, but they should be used with caution and not in all situations.
B. Administering prophylactic antibiotics: While prophylactic antibiotics are important in preventing infections in sickle cell anemia, this is not the immediate priority during a vaso-occlusive crisis.
C. Administering the pneumococcal vaccine: While vaccination is important, it is not a priority during a vaso-occlusive crisis.
D. Promoting bed rest: The nurse should assist the child to assume a comfortable position so that the child keeps the extremities extended to promote venous return; elevate the head of the bed no more than 30 degrees and avoid putting strain on painful joints.
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Related Questions
Correct Answer is D
Explanation
A. "I will ensure that my child takes a 1-hour nap each day." Prolonged inactivity, like frequent naps, may increase joint stiffness. Physical activity should be encouraged to maintain joint mobility.
B. "I will give my child prednisone as needed for pain." Prednisone is not typically used as needed for pain. NSAIDs are the first-line treatment for inflammation and pain in JIA.
C. "I will apply cool compresses to my child's painful joints during exacerbations." Warm compresses, not cool, are typically more effective in relieving joint stiffness in JIA.
D. "I will have my child wear splints during the night." Wearing splints at night helps maintain joint position and prevent contractures.
Correct Answer is C
Explanation
A. "The infant exhibits a fear of strangers." Stranger anxiety typically develops around 6 to 9 months of age.
B. "The infant understands the word 'no'." Understanding simple words like "no" begins closer to 9 months to 1 year of age.
C. "The infant has an absent grasp reflex." The grasp reflex begins to disappear by 3 months of age, with voluntary grasping developing by 4 to 5 months.
D. "The infant rolls from their back to their abdomen." Rolling from back to abdomen usually occurs around 5 to 6 months.
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