A nurse is assessing a child who is in a sickle cell crisis. Which of the following findings should the nurse expect?
Constipation
Pain
High fever
Bradycardia
The Correct Answer is B
During a sickle cell crisis, the child experiences severe pain due to the sickled red blood cells blocking blood flow in the vessels, leading to tissue ischemia and infarction. Pain is the hallmark symptom of sickle cell crisis and can occur in various parts of the body, such as the abdomen, chest, back, joints, and extremities.
A. Constipation is not a common symptom of sickle cell crisis. It may be associated with other conditions but is not directly related to sickle cell crisis.
C. High fever is not a typical finding in sickle cell crisis. Fever may occur due to infections, which individuals with sickle cell disease are at increased risk of developing, but it is not a direct symptom of the crisis itself.
D. Bradycardia (slow heart rate) is not commonly associated with sickle cell crisis. Tachycardia (rapid heart rate) may occur in response to pain, but bradycardia is not a typical finding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["260 mL"]
Explanation
To calculate the total fluid intake, we need to convert all the measurements to milliliters (mL) and then add them up:
1 cup = 240 mL
1 oz = 30 mL
Given fluid intake:
Juice: ½ cup = 0.5 * 240 mL = 120 mL
Gelatin: 3 oz = 3 * 30 mL = 90 mL
Ice pop: 1 oz = 1 * 30 mL = 30 mL
Ginger ale: 20 mL
Total fluid intake = 120 mL + 90 mL + 30 mL + 20 mL = 260 mL
So, the nurse should record 260 mL as the child's fluid intake.
Correct Answer is B
Explanation
Following a cardiac catheterization, the nurse should provide the parent with appropriate discharge instructions to ensure the child's proper recovery. The correct instruction to include is option B: "Give the child acetaminophen for discomfort."
Explanation:
Option A: Offering the child clear liquids for the first 24 hours is not a typical instruction following a cardiac catheterization. After the procedure, the child may be allowed to resume a regular diet, as tolerated, based on the healthcare provider's orders.
Option B: This is the correct instruction. After cardiac catheterization, the child may experience some discomfort at the insertion site or the area where the catheter was threaded through the blood vessels. Acetaminophen can be used to manage mild pain or discomfort.
Option C: Taking a tub bath for the first 3 days is not typically mentioned in discharge instructions after a cardiac catheterization. The nurse might advise the parent to avoid submerging the catheter insertion site in water for a specific period and instead use sponge baths until permitted by the healthcare provider.
Option D: Keeping the child home for 1 week is not a standard recommendation for a cardiac catheterization. The recovery period after a cardiac catheterization is usually shorter, and the child can often resume normal activities within a day or two, depending on the specific circumstances of the procedure and the child's condition.
The nurse should thoroughly review the specific discharge instructions provided by the healthcare provider and ensure the parent understands the care required at home, including any restrictions on activities or signs of potential complications that require immediate attention.
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