An 11-year-old patient with sickle cell anemia is admitted to the hospital with vaso-occlusive crisis. He is experiencing pain in his left elbow. The nurse needs to monitor the patient for which symptom?
Ketonuria.
Diplopia.
Severe abdominal pain.
Hyperactive patellar reflex.
The Correct Answer is D
Choice A rationale:
Ketonuria is the presence of ketones in urine and is not directly associated with vaso-occlusive crisis in sickle cell anemia. This crisis typically involves pain and ischemia in various body parts.
Choice B rationale:
Diplopia refers to double vision and is not a typical symptom of vaso-occlusive crisis. Pain, not vision changes, is the primary concern in this scenario.
Choice C rationale:
Severe abdominal pain can be a symptom of vaso-occlusive crisis in sickle cell anemia, but the patient's complaint of left elbow pain would not directly correlate with this choice.
Choice D rationale:
Hyperactive patellar reflex is the correct answer. During vaso-occlusive crisis, the body's response to pain can lead to increased muscle tone and reflexes, including hyperactive deep tendon reflexes like the patellar reflex. This is an indicator of neurologic involvement in the crisis. Remember that these rationales are intended to provide a concise understanding of the correct answers based on the information provided in the questions. Always refer to medical literature and consult with healthcare professionals for comprehensive and accurate information.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Stomatitis, inflammation of the oral mucosa, can make eating painful, leading to inadequate nutritional intake. The discomfort caused by stomatitis can discourage the patient from eating, potentially resulting in malnutrition. Ensuring adequate nutritional intake is crucial to support the patient's immune system and healing during antineoplastic therapy.
Choice B rationale:
Dental caries are not directly related to stomatitis. Stomatitis is inflammation of the oral mucosa, whereas dental caries involve decay of tooth structure due to bacterial action on food debris and sugars.
Choice C rationale:
Diarrhea is unrelated to stomatitis. Diarrhea involves frequent, loose, or watery stools, often caused by gastrointestinal infections, certain medications, or dietary intolerances.
Choice D rationale:
Gingival hyperplasia is an overgrowth of gum tissue and is not a likely result of stomatitis. It can be associated with some medications like anticonvulsants.
Correct Answer is B
Explanation
Choice A rationale:
Placing the patient in halo traction is not applicable for a scoliosis correction surgery with Harrington rods. Halo traction is typically used for cervical spine injuries or deformities, not for scoliosis correction.
Choice B rationale:
The correct answer. After Harrington rod insertion, maintaining proper alignment is crucial to prevent complications. Using a log-roll technique when turning the patient helps maintain spinal alignment and prevent stress on the surgical site.
Choice C rationale:
Keeping the patient nothing by mouth for 72 hours is not typically necessary after scoliosis surgery. Clear fluids and a light diet are usually initiated shortly after surgery.
Choice D rationale:
Restricting visitors for 48 hours is not a standard practice after scoliosis surgery unless there are specific infection control concerns, which are not mentioned in the scenario.
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