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 C
Explanation
A. Incorrect. Ensuring the device inspection sticker is current is important but not the first action to take when there's a potential safety issue.
B. Incorrect. Reporting the defect is important, but immediate action to ensure client safety should come first.
C. Correct. The nurse's first priority should be ensuring client safety. Removing the device from the room prevents any potential harm from using the device with a frayed cord.
D. Incorrect. Initiating a requisition for a replacement is important, but immediate action to ensure safety is a higher priority.
Correct Answer is A
Explanation
A. Administering the medication 30 minutes earlier may not be appropriate without specific orders from the provider.
B. Infusing the medication at a faster rate is not a solution for adjusting the timing of the dose.
C. Administering the medication up to 2 hours after the usual schedule time is incorrect because it could lead to subtherapeutic levels and reduced effectiveness.
D. Adjusting the medication schedule solely for the convenience of the client without consulting the provider is not recommended.
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