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 A
Explanation
A. Initiate droplet precautions. Pertussis (whooping cough) is transmitted via respiratory droplets. Droplet precautions are necessary to prevent the spread of the disease through coughs or sneezes.
B. Initiate a protective environment. A protective environment is used for patients with severe immunocompromised conditions to protect them from infections, not to prevent the spread of respiratory infections like pertussis.
C. Initiate contact precautions. Contact precautions are used for infections spread by direct or indirect contact with the patient or their environment, such as MRSA. Pertussis is spread by droplets, not by contact.
D. Initiate airborne precautions. Airborne precautions are for diseases that are spread through airborne particles, such as tuberculosis or measles. Pertussis is not airborne but spread through larger respiratory droplets.
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.
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