A nurse is assisting with the plan of care for a client who is experiencing sickle cell crisis. Which of the following interventions should the nurse include in the plan of care?

Provide a diet that is low in protein.

Avoid administration of the influenza vaccine.

Maintain the client on bed rest.

Decrease fluid intake to 1,500 mL daily.

Answer and Explanation

The Correct Answer is C

A. Provide a diet that is low in protein: This is incorrect because clients in sickle cell crisis require a well-balanced diet with adequate protein, along with increased fluid intake to help maintain hydration and reduce the risk of further complications.
B. Avoid administration of the influenza vaccine: This is incorrect because vaccination, including the influenza vaccine, is important for preventing infections that can exacerbate sickle cell crises.
C. Maintain the client on bed rest: This is correct because bed rest helps to reduce the energy expenditure and stress on the body, which can help manage pain and prevent further complications during a sickle cell crisis.
D. Decrease fluid intake to 1,500 mL daily: This is incorrect because increased fluid intake is crucial in sickle cell crisis to help prevent dehydration and promote proper blood flow, thereby reducing the risk of vaso-occlusive episodes.

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Correct Answer is A

Explanation

A. "I would like to see what this looks like today": This indicates effective coping as the client is engaging with their condition and facing the changes directly, which is an important step in emotional adjustment and recovery.
B. "I'm going to close my eyes until you are done dressing my incision": This suggests avoidance of the situation, which may indicate difficulty in coping with the reality of their condition.
C. "I would just like to spend my day staring at the TV": This may indicate withdrawal or avoidance, which is not an effective coping strategy.
D. "I'm planning to stay at home until my breast reconstructive surgery": While this may be part of the client's plan, it does not directly indicate effective coping with the current situation.

A. "My urine comes out whenever I sneeze." B. "It seems like my bladder empties without warning." C. "I have urine incontinence whenever I take a diuretic." D. "My urine seems to dribble out frequently."

Correct Answer is D

Explanation

A. "My urine comes out whenever I sneeze": This indicates stress incontinence, where urine leakage occurs with physical activities that increase abdominal pressure.
B. "It seems like my bladder empties without warning": This suggests urge incontinence, characterized by a sudden and intense urge to urinate.
C. "I have urine incontinence whenever I take a diuretic": This statement is more related to the effects of diuretics rather than a specific type of urinary incontinence.
D. "My urine seems to dribble out frequently": This is characteristic of overflow incontinence, where the bladder becomes overfilled and urine dribbles out due to inadequate emptying.

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A nurse is assisting with the plan of care for a client who is experiencing sickle cell crisis. Which of the following interventions should the nurse include in the plan of care?

Nursing Test Bank

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