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 ["25"]
Explanation
Step 1 is: Subtract the dry diaper weight from the wet diaper weight to find the weight of the urine. 75 grams - 50 grams = 25 grams.
Step 2 is: Convert the weight of the urine from grams to milliliters, as 1 gram of urine is approximately equal to 1 mL. 25 grams = 25 mL. The urine output is 25 mL.
Correct Answer is A
Explanation
Choice A rationale
Methylergonovine is an ergot alkaloid that directly stimulates sustained uterine contractions. This action is crucial in controlling postpartum hemorrhage by compressing blood vessels within the myometrium, thereby reducing blood loss. The observed excessive bleeding with this delivery necessitates intervention to prevent complications like hypovolemic shock. Its pharmacological effect targets smooth muscle receptors in the uterus.
Choice B rationale
Routine prescription based solely on parity (number of previous pregnancies) is not standard medical practice. Methylergonovine is administered based on clinical indication, primarily to prevent or manage postpartum hemorrhage, which is determined by factors like uterine atony or excessive bleeding, not simply the number of previous births. Unnecessary administration can lead to adverse effects.
Choice C rationale
While methylergonovine does contract the uterus and prevent excess bleeding, this response is a general statement. The best response directly addresses the client's current situation and her question about why *she* is receiving it *this time*. It is crucial to explain the specific clinical reason for her individual prescription, which in this context is likely due to the increased bleeding.
Choice D rationale
This response shifts the responsibility back to the client and does not provide the requested information. It fails to address the client's direct question about the medication's purpose in her specific situation. Providing clear and concise information is essential for client education and adherence to the treatment plan.
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