A nurse is caring for an adolescent who is having a sickle cell crisis. Which of the following nursing actions should the nurse take?
withhold opioids to avoid dependence
Assist RN with administering a blood transfusion
Initiate a 2 L/day fluid restriction
Encourage exercise
The Correct Answer is B
A. Withhold opioids to avoid dependence.
This option is incorrect. Opioid analgesics are commonly used to manage the severe pain associated with sickle cell crisis. Withholding opioids during a crisis could lead to inadequate pain relief and compromise the adolescent's comfort and recovery. It's important to appropriately administer opioids as prescribed to alleviate pain and suffering.
B. Assist RN with administering a blood transfusion.
This option may be appropriate depending on the severity and indications of the sickle cell crisis. Blood transfusions are sometimes used to treat sickle cell crises, particularly in cases of severe anemia or acute complications such as acute chest syndrome. However, the decision to administer a blood transfusion should be made by the healthcare provider based on the individual patient's clinical status and needs. The nurse's role would include assisting the registered nurse (RN) with the administration of the transfusion and monitoring the adolescent for any adverse reactions.
C. Initiate a 2 L/day fluid restriction.
This option is incorrect. During a sickle cell crisis, it is important to maintain adequate hydration to help prevent dehydration and reduce the viscosity of blood, which can help prevent sickling of red blood cells. Fluid intake should be encouraged, and there is typically no need for fluid restriction unless there are specific medical reasons to do so.
D. Encourage exercise.
This option is incorrect. During a sickle cell crisis, the adolescent is likely experiencing significant pain and discomfort, which may limit their ability to engage in physical activity. Encouraging exercise during a crisis could exacerbate pain and potentially lead to complications. Rest and minimizing physical exertion are typically recommended during a sickle cell crisis to promote comfort and conserve energy.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "Your child's diet should be high in carbohydrates & proteins with no restriction of fats."
This statement is not entirely accurate. While it's true that children with cystic fibrosis often require a diet that is higher in calories and protein to support growth and weight gain, there is typically a need to restrict fat intake. Pancreatic insufficiency, which is common in cystic fibrosis, can lead to malabsorption of fats and fat-soluble vitamins. Therefore, a dietitian may recommend enzyme replacement therapy and a diet that is moderate in fat but high in calories and protein.
B. "Limit your child's intake of sodium to avoid complications."
This statement is not accurate. Cystic fibrosis can lead to excessive loss of salt in sweat, which can contribute to dehydration and electrolyte imbalances. Therefore, limiting sodium intake can cause electrolyte disturbances.
C. "A pigeon-shaped chest might become evident as the disease progresses."
This statement is accurate. Cystic fibrosis can cause chronic lung infections and inflammation, leading to structural changes in the chest over time. One common manifestation is a barrel-shaped or "pigeon-shaped" chest, which can occur as the disease progresses. This may result from hyperinflation of the lungs due to air trapping and chronic respiratory compromise.
D. "Administer a bronchodilator to the child after chest percussion therapy."
This statement is not necessarily accurate or applicable to all cases. Bronchodilators are medications used to help relax and open the airways in conditions such as asthma or chronic obstructive pulmonary disease (COPD). While bronchodilators may be part of the treatment regimen for some individuals with cystic fibrosis, their use after chest percussion therapy would depend on the individual's specific respiratory symptoms and treatment plan. It's important for the parents to follow the healthcare provider's instructions regarding medication administration.
Correct Answer is B
Explanation
A. Decreased stridor: Stridor is a high-pitched, noisy breathing sound caused by turbulent airflow through a narrowed or partially obstructed airway. In laryngotracheobronchitis, stridor is often present and may worsen with increasing airway obstruction. Therefore, decreased stridor would not be a typical finding associated with airway obstruction in this condition.
B. Increased restlessness: Increased restlessness can be a sign of worsening respiratory distress and impending airway obstruction. As the child struggles to breathe, they may become increasingly agitated and restless, indicating the need for prompt intervention to ensure adequate oxygenation.
C. Decreased heart rate: Decreased heart rate (bradycardia) is not typically associated with airway obstruction in laryngotracheobronchitis. In fact, the heart rate may increase as a compensatory response to hypoxia and respiratory distress.
D. Decreased temperature: Changes in temperature are not typically associated with airway obstruction in laryngotracheobronchitis. The focus of monitoring in this condition is primarily on respiratory distress and signs of worsening airway obstruction.
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