A swollen joint.
The practical nurse (PN) is caring for a 20-month-old toddler who was admitted with a sickle cell crisis.
The mother rocks the toddler who continues to cry, is restless, and does not wish to be touched.
The electronic monitoring device indicates that the toddler's temperature is 102° F (38.8° C), heart rate is 140 beats/minute, blood pressure 122/70 mm Hg, and oxygen saturation 98%. Which problem(s) should the PN document as the priority in the client's plan of care (POC)? Select all that apply.
Pink tinged urine.
Palpitation.
Acute pain.
Risk for Infection.
Correct Answer : C,D
Choice A rationale
Pink-tinged urine can be a symptom of various conditions, including kidney issues or urinary tract infections. While individuals with sickle cell crisis can experience kidney complications, pink-tinged urine is not a universal or primary manifestation of a vaso-occlusive crisis. The immediate priority is pain management and infection prevention.
Choice B rationale
Palpitations, an awareness of one's own heartbeat, can be a symptom of various cardiac issues or a physiological response to stress or pain. While the heart rate is elevated (140 bpm, normal for a toddler is 90-140 bpm), this is likely secondary to the severe pain the child is experiencing and not the primary problem to be addressed.
Choice C rationale
Acute pain is a hallmark and often excruciating symptom of a sickle cell crisis, resulting from vaso-occlusion and tissue ischemia. The toddler's crying, restlessness, and aversion to touch strongly indicate severe pain, making it an immediate priority for intervention to alleviate suffering and prevent further complications.
Choice D rationale
Risk for infection is a significant concern in sickle cell disease due to functional asplenia, which compromises the immune system's ability to fight encapsulated bacteria. Despite the normal oxygen saturation, the elevated temperature (102°F or 38.8°C) in a child with sickle cell disease warrants immediate attention due to the high risk of severe infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
While postpartum depression is a serious concern, immediately asking about suicidal thoughts without first establishing a broader understanding of the client's feelings can be premature and potentially alienating. It is essential to first assess the general emotional state and bonding difficulties before jumping to severe mental health concerns.
Choice B rationale
Explaining that this is a common feeling can minimize the client's distress and validate her experience, but it does not provide an avenue for her to express her specific concerns or for the PN to fully assess the depth of her feelings. It can prematurely close off further discussion and assessment.
Choice C rationale
Determining if her husband is bonding with the baby shifts the focus away from the client's own feelings and experiences, which is the primary concern in this situation. While partner involvement is important, the immediate priority is to understand and address the client's reported lack of bonding.
Choice D rationale
Encouraging the client to talk about her feelings provides an open and supportive environment for her to express her specific concerns regarding bonding. This allows the practical nurse to gather more information, assess the severity of the issue, and identify appropriate interventions or referrals if needed, promoting therapeutic communication.
Correct Answer is ["0.3"]
Explanation
Step 1 is to convert the child's weight from pounds to kilograms. 66 pounds ÷ 2.2 pounds/kg = 30 kg.
Step 2 is to calculate the total dose in milligrams. 0.01 mg/kg × 30 kg = 0.3 mg.
Step 3 is to calculate the volume to administer in milliliters. 0.3 mg ÷ (1 mg/mL) = 0.3 mL.
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