A nurse is contributing to the plan of care for a school-age child who has sickle-cell disease and is experiencing a vaso-occlusive crisis. Which of the following should the nurse recommend to include in the plan of care?
Limit fluid intake during the evening
Perform passive range-of-motion exercises.
Apply cold compresses to painful areas.
Provide a low-protein diet
The Correct Answer is B
b. Perform passive range-of-motion exercises.
During a vaso-occlusive crisis in sickle-cell disease, blood flow to certain areas of the body may be restricted, leading to pain and tissue damage. Passive range-of-motion exercises can help promote blood circulation and prevent joint stiffness and further complications. These exercises involve gently moving the child's joints through their full range of motion without active participation from the child.
Explanation for the other options:
a. Limit fluid intake during the evening: Fluid intake is important in sickle-cell disease to prevent dehydration and maintain adequate blood flow. Restricting fluid intake during a vaso-occlusive crisis can further contribute to dehydration and may worsen the crisis. It is important to encourage fluid intake unless otherwise instructed by the healthcare provider.
c. Apply cold compresses to painful areas: Cold compresses are not recommended during a vaso-occlusive crisis in sickle-cell disease. Cold temperatures can cause vasoconstriction and further worsen the blood flow to affected areas, leading to increased pain and tissue damage. Warm compresses or warm packs may be used to promote vasodilation and provide pain relief.
d. Provide a low-protein diet: A low-protein diet is not specifically indicated in the plan of care for a vaso- occlusive crisis in sickle-cell disease. Adequate protein intake is important for overall nutritional needs and tissue repair. The focus of nutritional management in sickle-cell disease is usually on a well-balanced diet that includes adequate hydration and appropriate nutrient intake.
In summary, performing passive range-of-motion exercises is an appropriate intervention to include in the
plan of care for a school-age child experiencing a vaso-occlusive crisis in sickle-cell disease.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The nurse should recognize that the client needs a referral for diabetic education when the client lists sweating, shaking, and palpitations as symptoms of hyperglycemia. These symptoms are actually associated with hypoglycemia, not hyperglycemia. Hyperglycemia is characterized by symptoms such as increased thirst, frequent urination, and fatigue.
Option a is incorrect because drawing up regular insulin before NPH when demonstrating injection technique is the correct procedure.
Option b is incorrect because seeing a primary care provider to treat corns on the feet is an appropriate action for a client with diabetes.
Option c is incorrect because treating hypoglycemic reactions with 15 g of carbohydrates is the recommended treatment.
Correct Answer is C
Explanation
c. Irregular, bulging veins
Deep-vein thrombosis (DVT) is a condition characterized by the formation of a blood clot in the deep veins, commonly in the lower extremities. When assessing a client with DVT, the nurse should expect to find irregular, bulging veins in the affected extremity. This is due to the obstruction of blood flow caused by the clot, leading to distension and visible changes in the appearance of the veins.
Explanation for the other options:
a. Absent dorsal pedal pulse: Absent dorsal pedal pulse is not a characteristic finding of DVT. It may be associated with peripheral arterial disease, which is a different condition involving impaired blood flow in the arteries.
b. Shiny, hairless skin: Shiny, hairless skin is not a typical finding in the affected extremity with DVT. In fact,
the skin in the area of the clot may appear red, warm to touch, and swollen.
d. Dull, aching pain: Dull, aching pain may be present in the affected extremity with DVT. However, it is important to note that some individuals with DVT may not experience any pain or may have minimal discomfort. Therefore, the absence of pain does not rule out the possibility of DVT.
In summary, irregular, bulging veins are an expected finding in the affected extremity of a client with deep- vein thrombosis (DVT). It is important for the nurse to recognize and report these signs promptly to facilitate appropriate management and prevention of complications associated with DVT.
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