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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?

A.

Applying heat to the affected areas

B.

Administering prophylactic antibiotics

C.

Administering the pneumococcal vaccine

D.

Promoting bed rest

Answer and Explanation

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 {"A":{"answers":"B"},"B":{"answers":"A,B"},"C":{"answers":"A,B"},"D":{"answers":"A,B"}}

Explanation

Cough

  • Hypertrophic Pyloric Stenosis: Pyloric stenosis typically causes forceful vomiting but does not cause coughing.
  • Gastroesophageal Reflux: Coughing can occur due to aspiration or irritation of the esophagus.

Recurrent Emesis

  • Hypertrophic Pyloric Stenosis: Projectile vomiting after feedings is a hallmark sign of pyloric stenosis.
  • Gastroesophageal Reflux: GER can also cause recurrent vomiting, though it is usually less forceful than in pyloric stenosis.

Inadequate Weight Gain

  • Hypertrophic Pyloric Stenosis: The inability to retain feedings can lead to poor weight gain.
  • Gastroesophageal Reflux: Reflux can also result in poor weight gain if feedings are frequently vomited.

Irritability

  • Hypertrophic Pyloric Stenosis: Hunger due to inadequate feeding can cause irritability.
  • Gastroesophageal Reflux: Discomfort from esophageal irritation can lead to irritability.

Correct Answer is ["A","B","C"]

Explanation

A. "I should eat extra food on busy days when I am more active." Physical activity lowers blood glucose levels. Eating extra food prevents hypoglycemia during periods of increased activity.
B. "I should increase my intake of sugar-free fluids when I am sick." During illness, maintaining hydration is essential. Sugar-free fluids help prevent dehydration without causing hyperglycemia.
C. "I should eat a snack 30 minutes before my baseball game starts." A pre-activity snack helps maintain blood glucose levels during exercise, reducing the risk of hypoglycemia.
D. "I should wait 2 hours after eating before playing with my friends." There is no need to delay physical activity for 2 hours after eating unless instructed otherwise by a healthcare provider.
E. "I should have a 16-ounce glass of milk if I start feeling weak or shaky." A smaller portion of fast-acting carbohydrates, like 4 ounces of juice or 15 grams of glucose tablets, is recommended for treating hypoglycemia.

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