A 9-month-old with Tay-Sachs disease is admitted due to seizures. Which assessment is most important for the nurse to obtain?

Choice A reason: Giving prescribed intravenous antibiotics is not the first action that the nurse should take. Antibiotics are used to treat the infection and inflammation caused by appendicitis, but they are not enough to prevent the complications of a ruptured appendix. The nurse should administer the antibiotics as ordered, but only after notifying the healthcare provider of the change in the child's condition.

Choice B reason: Inquiring about the client's last meal is not the first action that the nurse should take. The last meal may be relevant for the preparation of the surgery, but it is not urgent or related to the sudden relief of pain. The nurse should ask about the last meal as part of the preoperative assessment, but only after contacting the healthcare provider.

Choice C reason: Contacting the healthcare provider is the first action that the nurse should take. Sudden relief of pain in a child with appendicitis may indicate a perforation or rupture of the appendix, which is a life-threatening emergency. The nurse should immediately report this finding to the healthcare provider, who may order additional tests or expedite the surgery.

Choice D reason: Documenting the client's relief of pain is not the first action that the nurse should take. Documentation is an important part of nursing care, but it is not a priority in this situation. The nurse should document the child's pain level, vital signs, and interventions, but only after contacting the healthcare provider and taking appropriate actions.

Choice A reason: Chest pain is a sign of acute chest syndrome, which is a life-threatening complication of sickle cell crisis. It occurs when the sickle-shaped red blood cells block the blood vessels in the lungs, causing inflammation, infection, and low oxygen levels. Chest pain may be accompanied by fever, cough, shortness of breath, and wheezes. The nurse should report chest pain to the health care provider immediately and monitor the child's vital signs, oxygen saturation, and respiratory status.

Choice B reason: Jaundice is a common finding in children with sickle cell disease, but it is not an urgent sign of sickle cell crisis. Jaundice occurs when the red blood cells break down faster than the liver can process them, resulting in a buildup of bilirubin in the blood and skin. Jaundice may cause yellowing of the skin, eyes, and mucous membranes, as well as itching and dark urine. The nurse should assess the child's liver function and hydration status, but jaundice does not require immediate intervention.

Choice C reason: Ulcers on the legs are a chronic complication of sickle cell disease, but they are not an acute sign of sickle cell crisis. Ulcers on the legs occur when the blood flow to the skin is impaired by the sickle-shaped red blood cells, causing tissue damage and infection. Ulcers on the legs may cause pain, swelling, and drainage, and they may take a long time to heal. The nurse should clean and dress the ulcers, apply topical antibiotics, and elevate the legs, but ulcers do not require immediate intervention.

Choice D reason: Swelling in the hands or feet is a common finding in children with sickle cell disease, especially in infants and toddlers, but it is not a critical sign of sickle cell crisis. Swelling in the hands or feet occurs when the sickle-shaped red blood cells block the blood vessels in the extremities, causing inflammation and fluid retention. Swelling in the hands or feet may cause pain, stiffness, and difficulty moving the joints. The nurse should apply warm compresses, massage the affected areas, and encourage the child to exercise the joints, but swelling does not require immediate intervention.