A nurse is collecting data from a child who has sickle disease and is experiencing a vaso-occlusive crisis. Which of the following findings should the nurse expect?
Pain
Vomiting
Constipation
Bradycardia
The Correct Answer is A
A. Pain: This is the most common and significant symptom of a vaso-occlusive crisis in sickle cell disease. The sickled cells block blood flow, leading to intense pain and tissue ischemia.
B. Vomiting: Vomiting is not a typical finding associated with a vaso-occlusive crisis. While it may occur due to other complications or treatments, it is not directly related to the crisis itself.
C. Constipation: Constipation is not a typical symptom of a vaso-occlusive crisis. It may occur due to decreased activity or medication side effects, but it is not directly linked to the sickle cell crisis.
D. Bradycardia: Bradycardia is not expected in a vaso-occlusive crisis. The crisis usually involves pain and stress, which might increase the heart rate rather than decrease it.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Remove the window and view the incision. Inspecting the incision through the cast window is important for monitoring for signs of infection or complications, but it is not the first priority. Ensuring the extremity has adequate circulation and function is critical initially.
B. Medicate the client for pain. Pain management is essential, especially postoperatively, but assessing the integrity and function of the affected extremity takes precedence to ensure there are no immediate complications like compromised circulation or nerve damage.
C. Perform neurovascular checks of the affected extremity. Performing neurovascular checks is the highest priority to ensure that circulation, sensation, and movement are intact. This helps identify any immediate issues with the cast or complications from surgery that could jeopardize the limb’s health.
D. Turn the client so the cast will dry on all sides. Ensuring the cast dries properly is important to maintain its integrity and effectiveness, but this action is secondary to assessing neurovascular status to prevent serious complications.
Correct Answer is A
Explanation
A. Heart rate 110/min: A heart rate of 110 beats per minute is within the normal range for a 4-year-old child. The typical heart rate for this age is between 80 to 120 beats per minute.
B. Capillary refill greater than 3 seconds: Capillary refill time should be less than 2 seconds in a healthy child. A refill time greater than 3 seconds may indicate poor perfusion or dehydration, which is abnormal.
C. Weight gain of 0.9 kg (2 lb) in a year: A weight gain of 2 pounds in a year is below the expected range for a 4-year-old. Children in this age group typically gain around 4-5 pounds per year as they grow.
D. Respiratory rate 32/min: The normal respiratory rate for a 4-year-old child is typically between 20 to 30 breaths per minute. A rate of 32/min is slightly elevated and may indicate respiratory distress or other issues.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today