A nurse is caring for a child in the PACU following a tonsillectomy. Which of the following findings requires immediate intervention by the nurse?

A. Instruct the parent to ensure the pneumococcal vaccine is current.
This is a preventive measure to reduce the risk of infections in individuals with sickle cell disease.

B. Give oral hydroxyurea.
Hydroxyurea is used to decrease the frequency of pain episodes in sickle cell disease.

C. Monitor oxygen saturation continuously.
Continuous monitoring of oxygen saturation is important to detect any potential respiratory complications.

D. Place the client on strict bed rest.
Bed rest helps to reduce the metabolic demands on the body and promotes healing.

E. Restrict oral intake.
During a sickle cell crisis, it's generally not necessary to restrict oral intake unless there are specific indications to do so, such as severe abdominal pain or vomiting that prevents the child from tolerating oral feeds.

F. Apply cold compresses to the affected joints. Administer meperidine IV for pain.
Cold compresses may exacerbate vaso-occlusion, and meperidine is not the first-line choice for pain management in sickle cell crisis due to potential neurotoxicity.
G. Administer meperidine IV for pain.
Meperidine has a relatively short duration of action, which may necessitate frequent dosing. This can lead to more fluctuations in pain control.

H. Administer folic acid as prescribed.
Folic acid supplementation is often recommended for individuals with sickle cell disease to support red blood cell production.

A. Administering an antidepressant is an important intervention for a client with major depressive disorder. However, before initiating any treatment, it is crucial to assess the client's risk for self-harm or suicidal ideation.

B. Assisting the client in completing activities of daily living (ADLs) is important for their overall well-being, but the most immediate concern for a client with major depressive disorder is to assess their safety and risk for self-harm.

C. Correct. Assessing the client's risk for self-harm or suicidal ideation is the first priority.
This information will help determine the level of intervention and support needed.

D. Encouraging the client to attend group therapy is a valuable intervention, but it is not the first priority. Safety concerns must be addressed before implementing other
therapeutic interventions.