A nurse is teaching the parents of a school-age child who has sickle cell anemia about managing the disease at home.
Which of the following instructions should the nurse include?

Report sudden, persistent headaches.

Apply cold compresses to painful areas.

Restrict fluid intake during times of stress.

Avoid meningococcal immunizations.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

The nurse should instruct the parents to report sudden, persistent headaches in a child with sickle cell anemia because it could be a sign of a cerebrovascular accident (stroke) Sickle cell anemia predisposes individuals to vaso-occlusive crises, which can lead to stroke due to impaired blood flow. Early detection and intervention are crucial in preventing complications.

Choice B rationale:

Applying cold compresses to painful areas may help in managing pain during vaso-occlusive crises, but it is not as critical as identifying signs of more severe complications such as stroke. This instruction does not address the urgency of reporting sudden, persistent headaches.

Choice C rationale:

Restricting fluid intake during times of stress is not appropriate for a child with sickle cell anemia. In fact, maintaining adequate hydration is important to prevent vaso-occlusive crises. Dehydration can exacerbate sickling of red blood cells, leading to more pain and complications.

Choice D rationale:

Avoiding meningococcal immunizations is not appropriate for a child with sickle cell anemia. In fact, children with sickle cell disease are at an increased risk of infections, including meningitis. Immunizations, including those for meningococcus, are essential to prevent life-threatening infections in these individuals.

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Correct Answer is D

Explanation

As explained, holding the bottle directly over the sterile field can result in contamination. It's crucial to pour the solution from above or to the side of the sterile field, making sure the bottle doesn't touch the field or anything in the field. This minimizes the risk of contaminating the sterile setup.

If solution is spilled on the sterile field, that area is contaminated, and you cannot make it sterile again by covering it with gauze. The correct approach would be to discard the contaminated items and set up a new sterile field.

While it's important not to touch the label side of the bottle, this option doesn't address the action of placing the cap. The most important part of pouring a sterile solution is ensuring the cap stays sterile, which is what option D addresses.

When performing a sterile procedure, after removing the cap from a sterile bottle, the cap should be placed sterile-side up on a clean surface or a sterile field. This is because the sterile side of the cap should not touch any non-sterile surfaces, and placing it sterile-side up ensures it stays sterile.

A. Initiate seclusion protocol. B. Tell the client, "You seem to be very upset." C. Use a face shield with a mask when providing care to the client. D. Engage the panic alarm.

Correct Answer is B

Explanation

A. Incorrect. Initiating seclusion protocol should only be done in situations where the safety of the client or others is at risk and after appropriate assessment and intervention.

B. Correct. Acknowledging the client's emotions and showing empathy can help defuse the situation and promote effective communication.

C. Incorrect. Using personal protective equipment (face shield with mask) is not necessary when interacting with an agitated client unless there is a specific infection control concern.

D. Incorrect. Engaging the panic alarm is not necessary in this situation, as it may escalate the client's agitation.

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A nurse is teaching the parents of a school-age child who has sickle cell anemia about managing the disease at home.Which of the following instructions should the nurse include?

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A nurse is teaching the parents of a school-age child who has sickle cell anemia about managing the disease at home.
Which of the following instructions should the nurse include?