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

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

c. Hallucination

In the scenario described, the client's experience of receiving special audible messages from the Central Intelligence Agency that no one else can hear indicates a hallucination. Hallucinations are perceptual disturbances in which a person experiences sensory perceptions without any external stimuli. They can occur in any sensory modality, such as hearing (auditory hallucinations), seeing (visual hallucinations), smelling (olfactory hallucinations), tasting (gustatory hallucinations), or feeling (tactile hallucinations).

In this case, the client is experiencing auditory hallucinations, as he is perceiving auditory stimuli (audible messages) that are not present in the external environment. Auditory hallucinations are most commonly associated with schizophrenia, although they can occur in other psychiatric disorders as well.

Derealization (option a) refers to a subjective feeling of unreality or detachment from the environment. It involves a perception that the external world is strange, distorted, or unreal. This is not the primary alteration in perception described in the scenario.

Illusion (option b) is a misinterpretation or misperception of a real sensory stimulus. It occurs when a person's perception of an actual stimulus is distorted or misunderstood. There is no indication of a misperception of a real stimulus in the scenario.

Depersonalization (option d) is a subjective experience of being detached from one's own body, thoughts, or emotions. It involves a feeling of being outside of oneself or observing oneself from a distance. This is not the primary alteration in perception described in the scenario.

Therefore, the correct answer is c. Hallucination, as the client's experience of receiving special audible messages that no one else can hear represents an auditory hallucination.

A. "You can take your child to stores on weekends." B. "You should inspect your child's mouth weekly for ulcers." C. "You should notify your provider if your child has a fever." D. "You can give your child fresh fruit for snacks."

Correct Answer is C

Explanation

A nurse reinforcing discharge teaching with the guardian of a client who is neutropenic should include the instruction to notify the provider if the child has a fever. A fever can be a sign of infection, which can be serious in a client who is neutropenic.

The other options are not correct.

A client who is neutropenic should avoid crowded places such as stores to reduce their risk of infection. The guardian should inspect the child's mouth daily, not weekly, for ulcers. A client who is neutropenic should avoid fresh fruits as they may carry bacteria that can cause infection.

View Question and Answer

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

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse is reinforcing discharge teaching with the guardian of a client who is neutropenic. Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

A nurse is assisting with developing a discharge plan for a client who has a new diagnosis of diabetes mellitus. The client is independent and lives alone. Which of the following interventions should the nurse plan to include?

A nurse has obtained a client's oxygen saturation measurement of 88% on 2 liters of oxygen via nasal cannula. Which of the following actions should the nurse take?

A nurse is reinforcing teaching with a client who is about to undergo an upper gastrointestinal series with ﬂuoroscopy. Which of the following information should the nurse provide?

A nurse is visiting with the family of a client who has just died. Which of the following actions should the nurse take to promote comfort for the family?

A nurse is reinforcing discharge teaching with an older adult client who has osteoarthritis. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is providing care to a client who is immunocompromised. Which of the following should the nurse identify as a possible source of infection?

A nurse is caring for a client who has a new prescription for furosemide and asks the nurse about the purpose of the medication. The nurse states "This medication is a diuretic that removes excess ﬂuid from your body." Which of the following ethical concepts is the nurse exhibiting?

A nurse is reviewing the medical record of a client who has sustained a full-thickness burn and is in the emergent phase of the burn. Which of the following findings should the nurse expect?