A nurse is caring for an adolescent who has sickle-cell anemia. Which of the following manifestations indicates acute chest syndrome and should be immediately reported to the provider?

Rationale for correct choices:

• Electrolyte imbalance: The client’s potassium level of 3.0 mEq/L is critically low, contributing to premature ventricular contractions and orthostatic hypotension. These abnormalities place the client at immediate risk for cardiac dysrhythmias and require urgent correction to prevent life-threatening complications.
• View of body: The client voices fear of gaining weight and fixates on food, which are indicators of distorted self-perception. This impaired view of the body is a central feature of bulimia nervosa and needs to be addressed during psychotherapy once the client is medically stabilized.

Rationale for incorrect choices:

• Impaired body image: While body image concerns are common in eating disorders, this option is more general. “View of body” better captures the client’s psychological distortion and allows for more precise therapeutic interventions that address the cognitive roots of the disorder.
• Impaired coping: The client engages in maladaptive coping strategies like bingeing and purging. However, these behaviors are secondary to deeper distortions in self-image and medical instability. Coping can be addressed later in the treatment process once safety is ensured.
• History of anxiety: Anxiety is part of the client's long-standing history but is not causing the immediate physical risk. Addressing acute electrolyte disturbances and body image distortion takes precedence over chronic anxiety in this clinical setting.
• Obsession with food: Although the client’s persistent thoughts about food are important, they are symptoms driven by distorted body perception. Treating the underlying belief system about body image is more foundational and effective in resolving food-related obsessions.

Rationale:

A. The nurse positions a client who is postoperative in a semi-Fowler's position: Semi-Fowler's position is commonly used postoperatively to promote lung expansion, prevent aspiration, and support comfort. This is an appropriate nursing action that does not require correction.

B. The nurse performs auscultation of the lungs without lifting the gown: Lung auscultation should always be performed on bare skin to ensure accurate assessment of breath sounds. Clothing can muffle or distort the sounds, potentially leading to misinterpretation or missed abnormalities.

C. The nurse applies a cold compress to reduce localized swelling: Cold therapy is appropriate for managing inflammation, bruising, or swelling in many clinical settings. This demonstrates correct therapeutic intervention and does not indicate a need for further instruction.

D. The nurse uses clean gloves when administering an enema: Clean (non-sterile) gloves are appropriate for enema administration since it is a non-sterile procedure. This action follows standard precautions and is acceptable for routine nursing care.