A nurse is caring for an 8-year-old child who has sickle cell anemia and is recovering from a vaso-occlusive crisis. Which of the following precautions should the nurse include in the discharge teaching?
Drink eight glass of fluid daily.
Maintain an updated hemophilus influence type b immunisation
Avoid playground activities at school
Assume postural drainage positions every 6 hrs
The Correct Answer is A
A. Drink eight glasses of fluid daily: This is crucial advice for patients with sickle cell anemia, as adequate hydration helps prevent sickling of red blood cells and reduces the risk of vaso-occlusive crises. Therefore, this precaution is appropriate and should be included in discharge teaching.
B. Maintain an updated Haemophilus influenzae type b (Hib) immunization: While vaccination is essential for overall health, maintaining Hib immunization is not directly related to sickle cell anemia or vaso-occlusive crises. However, it's still important for the child's general well-being and should be addressed but may not be the priority in discharge teaching for sickle cell anemia.
C. Avoid playground activities at school: Children with sickle cell anemia are at risk of vaso-occlusive crises triggered by dehydration, fatigue, or extreme physical exertion. While playground activities can be strenuous, completely avoiding them may not be necessary. Instead, the child should be educated on the importance of staying hydrated, taking breaks when needed, and avoiding excessive physical strain.
D. Assume postural drainage positions every 6 hours: Postural drainage is not typically indicated for sickle cell anemia or vaso-occlusive crises unless there are specific respiratory complications. This precaution is not relevant to the management of sickle cell anemia and should not be included in discharge teaching for this condition.
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Related Questions
Correct Answer is D
Explanation
A. Promote maternal-infant bonding: While promoting maternal-infant bonding is essential for the overall well-being of the newborn and family, it may not be the priority in this situation. The immediate focus is on medical management and preventing complications associated with the myelomeningocele.
B. Provide age-appropriate stimulation: Age-appropriate stimulation is important for newborn development, but in the case of a newborn with a myelomeningocele awaiting surgery, the priority is to minimize any potential risk of injury or infection to the exposed neural tissue.
C. Educate the parents about the defect: Education about the myelomeningocele and its long-term implications is crucial for the parents' understanding and ability to care for their child. However, while important, this may not be the priority at the immediate moment.
D. Maintain integrity of the sac: This is the priority nursing goal in caring for a newborn with a myelomeningocele awaiting surgery. The sac covering the exposed neural tissue must be carefully protected to prevent infection and further damage. Measures such as keeping the sac moist with sterile saline dressings and preventing trauma to the area are essential to maintain its integrity.
Correct Answer is D
Explanation
A. "I will use powders & lotion on his skin around the harness clasps."
This statement indicates a misunderstanding. Powders and lotions should generally be avoided around the harness clasps because they can interfere with the proper fit of the harness and cause irritation or discomfort to the baby's skin.
B. “I will remove the harness daily, prior to giving the bath.”
This statement is incorrect. The Pavlik harness is typically not removed for bathing, as it needs to be worn continuously to maintain proper positioning of the hips and promote optimal healing. Removing the harness daily for bathing can disrupt the treatment process and delay progress.
C. "I will adjust the harness straps every day."
This statement indicates a misunderstanding. The harness should not be adjusted daily without guidance from the healthcare provider. The straps of the Pavlik harness are initially adjusted by the healthcare provider to ensure proper fit, and they should remain in place without frequent adjustments to maintain stability and effectiveness.
D. "I will check my baby's skin under the straps frequently."
This statement indicates an understanding of the teaching. It is essential for the mother to regularly check her baby's skin under the harness straps for any signs of irritation, redness, or pressure sores. Monitoring the skin closely allows for early detection of any issues that may arise from wearing the harness.
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