A pediatric client in sickle cell crisis comes to the hospital with his mother. When assessing the client, the nurse should expect to find which of the following manifestations?
Constipation
Bradycardia
Pain
Fever
The Correct Answer is C
A. Constipation is not typically associated with sickle cell crisis. While it can occur due to medications or dehydration, it is not a primary symptom of a crisis.
B. Bradycardia is not a typical manifestation of sickle cell crisis. The patient might experience tachycardia due to pain or dehydration.
C. Pain is the hallmark symptom of a sickle cell crisis. The sickle-shaped red blood cells obstruct blood flow, leading to ischemia and severe pain, often in the joints or abdomen.
D. Fever can occur if there is an infection, but pain is the most characteristic finding in a sickle cell crisis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. While the nurse is required to report, it is not the supervisor’s decision. The nurse should clarify that they are the mandated reporter.
B. Deferring the explanation to the supervisor avoids the nurse’s responsibility. The nurse should directly explain their duty.
C. Nurses are mandated reporters and are legally required to report suspected child abuse. This response is appropriate as it aligns with the nurse’s professional and legal responsibilities.
D. The nurse should address the issue, not refer to the provider for an explanation of their actions.
Correct Answer is A
Explanation
A. "I am going to listen to your heart" is the most appropriate way to introduce the process of taking vital signs, as it is non-threatening and familiar to the child.
B. "Can you stand still while I feel how warm you are?" may be confusing to a toddler, as they might not understand what "feeling warm" means.
C. "Can I listen to your lungs?" might sound unfamiliar or intimidating to a toddler.
D. "Can I take your blood pressure now?" is a more advanced procedure that may cause anxiety and should be introduced after explaining the other vital signs.
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