Patient Data

 

Exhibits

The client has started to wake up more, opening her eyes without stimulation and looking around the room.
Which should the nurse do as the client becomes more aware of her surroundings? Select all that apply.

Rationale for Correct Choices:

• Sickle cell crisis: The infant’s pallor, edema in hands and feet, irritability, poor feeding, decreased urine output, and recent infection align with a vaso-occlusive episode typical in sickle cell disease.

•IV and oral fluids decrease blood viscosity and improve circulation, which is essential to prevent worsening of vaso-occlusion and associated pain.

• As able, elevate extremities: Elevating affected extremities promotes venous return, reduces swelling, and alleviates discomfort during the crisis.

• Intake and output: Monitoring fluid balance is critical to detect dehydration or renal compromise, which are risks in sickle cell crises due to reduced perfusion and poor intake.

• White blood cell count: WBC monitoring helps detect infection, which can trigger or worsen a sickle cell crisis, and assesses the body’s inflammatory response during the acute event.

Rationale for Incorrect Choices:

• Leukemia: While leukemia can present with pallor and fatigue, the acute swelling of hands and feet, irritability, and trigger by recent infection are more characteristic of sickle cell crisis rather than leukemia.

• Pneumonia: Adventitious lung sounds are noted, but the primary presenting signs (pallor, extremity edema, decreased urine output, pain) are more consistent with sickle cell crisis; pneumonia alone would not explain extremity edema.

• Potential Condition: Stroke: Stroke in infants may cause focal neurological deficits or asymmetric movement, but this infant shows generalized extremity involvement without focal weakness, making stroke less likely.

• Initiate sliding scale insulin: There is no evidence of hyperglycemia requiring insulin; blood glucose monitoring is not indicated for the acute presentation.

• Cool the environment: Cooling can worsen vasoconstriction and precipitate a sickle cell crisis; it is contraindicated in vaso-occlusive episodes.

• Begin bilirubin light therapy: The infant does not present with jaundice or hyperbilirubinemia; phototherapy is not indicated.

• Blood glucose: There is no indication of hypoglycemia or hyperglycemia contributing to this presentation, so monitoring glucose is not priority.

• Clotting times: There is no evidence of coagulopathy or bleeding disorder in this scenario; monitoring clotting times is unnecessary.

• Bilirubin: The infant has no jaundice or lab evidence of hyperbilirubinemia, making bilirubin monitoring nonessential.

A. Complete blood count: Zidovudine can cause bone marrow suppression, leading to thrombocytopenia. Pinpoint red spots, or petechiae, are a sign of low platelet count. A CBC is the most relevant test to evaluate for cytopenias and should be reported promptly to the provider.

B. Skin biopsy: A biopsy would help diagnose dermatologic conditions such as rashes, lesions, or malignancies, but petechiae are usually vascular in nature and related to platelet abnormalities.

C. Allergy test: Allergy testing evaluates hypersensitivity to specific allergens but is not relevant here. Petechiae are not typical of allergic reactions; instead, they reflect impaired clotting or low platelets.

D. Electromyography: EMG measures electrical activity in muscles to assess for neuromuscular disorders. It has no connection to the client’s presentation of petechiae and is unrelated to zidovudine’s known adverse effects.