A nurse is contributing to the plan of care for a child who has sickle cell crisis. Which of the following actions should the nurse recommend to include?
Apply cold compresses to the affected areas.
Implement pain management on a PRN basis.
Active range-of-motion (ROM) exercises daily.
Promote hydration with IV and oral fluids.
The Correct Answer is D
A. Apply cold compresses to the affected areas. Cold can cause vasoconstriction, which may worsen the sickling and pain. Heat packs are generally recommended to promote circulation and relieve pain.
B. Implement pain management on a PRN basis. Pain management should be consistent and proactive rather than PRN (as needed). Regular pain control is essential in managing sickle cell crises.
C. Active range-of-motion (ROM) exercises daily. During a crisis, the child should rest and avoid physical activity to prevent further pain and complications. ROM exercises are more appropriate during non-crisis times for maintaining joint function.
D. Promote hydration with IV and oral fluids. Hydration is crucial during a sickle cell crisis as it helps to decrease blood viscosity, reducing the risk of further sickling and vaso-occlusive events.
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Related Questions
Correct Answer is D
Explanation
A. Maintain a saline-lock.Maintaining a saline lock is important for potential intravenous access, but it is not the most urgent priority compared to actions that directly monitor the child's condition and help manage the disease.
B. Parental education is important for long-term management and understanding of the condition, but it is not the most immediate priority in the acute phase of the illness.
C. A no-salt-added diet is important to help manage fluid retention and hypertension, which are common in acute glomerulonephritis. However, while important, it does not take immediate priority over assessing the child's fluid status.
D. Monitoring daily weight is crucial in acute glomerulonephritis, as it helps assess fluid balance and detect early signs of fluid retention or worsening kidney function, which are key concerns in this condition. This makes it a priority action.
Correct Answer is B
Explanation
A. Evaluate the child's self-esteem. Self-esteem evaluation is important in general nursing care but is not a specific intervention for managing urinary tract infections.
B. Encourage frequent voiding. Frequent voiding helps to flush out bacteria from the urinary tract and prevents stasis, which can reduce the risk of urinary tract infections.
C. Administer an antidiuretic. Antidiuretics reduce urine output and are not typically used in the treatment of urinary tract infections, which require adequate urine flow to flush out bacteria.
D. Restrict fluids. Adequate hydration is important in managing urinary tract infections to promote urine flow and help flush out bacteria. Fluid restriction is not appropriate unless otherwise indicated.
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