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:
Collaborating with the team to begin peritoneal dialysis is the priority nursing intervention for a 9-year-old child with assessment findings of low urine output, high creatinine, and elevated blood urea nitrogen. These indicators suggest acute kidney injury, and initiating peritoneal dialysis is crucial to remove waste products and excess fluids.
Choice B rationale:
Strictly monitoring intake and output is important, but the child's current lab values and condition indicate the need for more immediate intervention through dialysis.
Choice C rationale:
Ensuring a low-sodium, low-phosphorus, and low-protein diet is important for renal health, but it's not the priority over addressing the acute kidney injury.
Choice D rationale:
Monitoring blood pressure is relevant but does not address the acute kidney injury that requires immediate attention. Assessment Findings for Adolescent Client:
Choice A rationale:
Numbness and tingling feeling in her legs require immediate action. These symptoms could indicate nerve compression or compromised blood flow due to the rod placement and need prompt assessment to prevent complications.
Choice B rationale:
A fever of 100.4°F (38°C) after surgery is common and can be managed with appropriate interventions, but it's not the most urgent concern in this case.
Choice C rationale:
Pain at the incision site is expected after surgery and should be managed appropriately, but it's not an immediate priority over potential neurovascular issues.
Choice D rationale:
Sleeping with occasional snoring might be related to anesthesia or positioning but doesn't require immediate action compared to the potential complications indicated by numbness and tingling.
Correct Answer is C
Explanation
Choice A rationale:
Fever and hypertension are not typical findings in moderate dehydration. Dehydration often leads to hypotension rather than hypertension, and fever is not a direct consequence of dehydration.
Choice B rationale:
Increased specific gravity can be a sign of dehydration, but it is not as specific or sensitive as tachypnea (rapid breathing) and tachycardia (elevated heart rate), which occur due to the body's compensatory mechanisms in response to dehydration.
Choice C rationale:
Tachypnea and tachycardia are key indicators of moderate dehydration in infants. The body tries to maintain perfusion by increasing the heart rate and respiratory rate. These signs are more reliable indicators of dehydration than specific gravity or fever.
Choice D rationale:
Bulging posterior fontanel is not a typical finding in dehydration. A sunken fontanel might be more indicative of dehydration, as fluid shifts from the intracellular to the extracellular space.
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