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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Correct. In cases where the client is unable to provide informed consent due to incapacitation, the health care surrogate or legally authorized representative should be involved in the decision-making process.
B. Incorrect. While family support is important, the decision for surgery should primarily be based on medical necessity and the best interests of the client.
C. Incorrect. Determining medical necessity is the responsibility of the medical team, not the nurse.
D. Incorrect. Sending the unsigned informed consent form to the risk manager is not a standard nursing responsibility and does not address the issue of informed consent.
Correct Answer is D
Explanation
Incorrect. Obesity is not a contraindication for acupuncture.
B. Incorrect. Hypothyroidism is not a contraindication for acupuncture.
C. Incorrect. Hypertension is not a contraindication for acupuncture.
D. Correct. Herpes zoster (shingles) involves a reactivation of the varicella-zoster virus and can cause skin lesions. Acupuncture involves the insertion of needles through the skin, which could potentially worsen the condition or lead to the spread of the virus.
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