A nurse is caring for an adolescent who is admitted with a vaso-occlusive crisis.
The nurse is planning care for the adolescent. Select the 5 interventions the nurse should include.
Instruct the parent to ensure the pneumococcal vaccine is current.
Give oral hydroxyurea.
Monitor oxygen saturation continuously.
Place the client on strict bed rest.
Apply cold compresses to the affected joints.
Administer meperidine IV for pain.
Correct Answer : A,B,C,D,H
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
- A: Tighten the screws on the halo device one-quarter turn every 48 hr.
- Rationale: This action is incorrect because the screws on a halo device should not be adjusted by the nurse. The screws are typically set and secured by a healthcare provider, and any adjustments can compromise the integrity of the device and the stability of the cervical spine.
- B: Assess the pin sites for infection once every other day.
- Rationale: While it is important to monitor the pin sites for signs of infection, doing so once every other day may not be sufficient. Pin sites should be assessed at least once per shift to ensure early detection and management of any potential infection.
- C: Encourage flexion and extension of the neck.
- Rationale: This action is contraindicated for a client with a halo vest. The purpose of the halo vest is to immobilize the cervical spine to promote healing. Encouraging neck movement could cause further injury or delay healing.
- D: Reposition the client using a turning sheet.
- Rationale: This is the correct action. Using a turning sheet helps to reposition the client safely and effectively without exerting unnecessary pressure on the cervical spine. It also aids in preventing pressure ulcers and promotes comfort for the client.
Correct Answer is D
Explanation
A. Nightmares are common in children and may not be directly related to the brain tumor. While they should be addressed, they are not the priority in this case.
B. Hyperactivity can be a normal behavior in preschoolers. It may or may not be related to the brain tumor. Other symptoms should take precedence.
C. Pruritus (itching) is a common symptom that can have various causes, and it may not be directly related to the brain tumor. It should be addressed but is not the priority in this case.
D. Correct. Diplopia (double vision) can be a neurological symptom associated with increased
intracranial pressure or other complications related to a brain tumor. It is important to report this finding promptly to the provider for further evaluation and intervention.
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