The 8-year-old client diagnosed with a vaso-occlusive sickle cell crisis is complaining of a severe headache.
Which intervention should the nurse implement first?
Administer 6 L of oxygen via nasal cannula.
Assess the client's neurological status.
Administer a narcotic analgesic by IV push.
Increase the client's IV rate.
The Correct Answer is B
Choice A rationale
Administering 6 L of oxygen is an important intervention in sickle cell crisis to address tissue hypoxia. However, a severe headache in a child with vaso-occlusive crisis may signal a more critical complication like a cerebrovascular accident (stroke), which necessitates immediate neurological assessment before other routine interventions.
Choice B rationale
A severe headache in a child experiencing a sickle cell vaso-occlusive crisis is a red flag for central nervous system complications, most critically a stroke, which requires immediate and detailed neurological assessment. Establishing the baseline status is the priority to rapidly detect changes and initiate emergency stroke protocol and treatment.
Choice C rationale
Administering a narcotic analgesic is crucial for pain management in a vaso-occlusive crisis. However, giving an opioid before assessing neurological status could potentially mask or alter signs of a life-threatening stroke or increased intracranial pressure, delaying critical interventions for a neurological emergency.
Choice D rationale
Increasing the IV rate is an appropriate intervention to promote hydration and hemodilution, which can help reverse the sickling process. While important, addressing the severe headache requires first ruling out or confirming a serious neurological event through a focused assessment, making assessment the immediate priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A nurse is preparing a presentation for an expectant parent group about neural tube defects and how to prevent them.
Which would the nurse emphasize?
Correct Answer is ["B","C","D","E"]
Explanation
Choice A rationale
Children with hemophilia have a deficiency in a specific clotting factor (Factor VIII for Hemophilia A, Factor IX for Hemophilia B), which significantly impairs the coagulation cascade and places them at extremely high risk for life-threatening bleeds from trauma. Participation in high-impact or contact sports, such as football or hockey, must be strictly avoided to prevent spontaneous or injury-induced deep tissue, joint, or intracranial hemorrhage.
Choice B rationale
Due to the high risk of bleeding, any procedure that penetrates the muscle and potentially damages blood vessels, like intramuscular (IM) injections, should be minimized or avoided. Subcutaneous (SubQ) injections are preferred for necessary immunizations because they cause less trauma to blood vessels and have a lower risk of causing a deep hematoma, although firm pressure must still be applied afterward.
Choice C rationale
A joint injury, such as a knee hemarthrosis, is a common and serious complication of hemophilia, causing severe pain and swelling. Initial management involves RICE (Rest, Ice, Compression, Elevation). Immobilization of the affected joint is crucial to prevent further movement that could aggravate bleeding, reduce pain, and preserve joint function until the bleeding is controlled, usually with factor replacement therapy.
Choice D rationale
Pain management in a child with hemophilia must strictly avoid nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or aspirin, as these medications inhibit platelet aggregation and increase the risk of bleeding. Acetaminophen is the analgesic of choice because it does not affect platelet function or increase bleeding risk, providing a safe option for managing mild to moderate pain, including that from hemarthrosis.
Choice E rationale
Epistaxis (nosebleeds) is a common bleeding episode in children with hemophilia. The appropriate initial intervention is to apply direct, continuous compression to the soft lower part of the nose for at least 10 minutes while tilting the head forward to prevent blood from flowing down the throat. Applying an ice pack to the bridge of the nose or the back of the neck causes vasoconstriction, which can help to slow the bleeding.
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