A school-age child is admitted in vaso-occlusive sickle cell crisis. The child's care should include which intervention? (Select all that apply.).
Correction of acidosis.
Adequate hydration.
Pain management.
Administration of heparin.
Replacement of factor VIII.
Correct Answer : B,C,E
Choice A rationale:
Correction of acidosis is not the primary intervention for vaso-occlusive sickle cell crisis. The crisis primarily involves pain due to the obstruction of blood flow by sickled cells. Correcting acidosis is not a direct treatment for this condition.
Choice B rationale:
Adequate hydration is essential in managing vaso-occlusive sickle cell crisis. Proper hydration helps prevent dehydration, which can worsen the crisis and lead to complications. Hydration helps maintain blood flow and prevent further sickling of red blood cells.
Choice C rationale:
Pain management is a crucial intervention for a child with vaso-occlusive sickle cell crisis. Pain results from tissue ischemia caused by sickled red blood cells. Effective pain management, often with analgesics, helps improve the child's comfort and quality of life during the crisis.
Choice D rationale:
Administration of heparin is not indicated for vaso-occlusive sickle cell crisis. Heparin is an anticoagulant that prevents blood clot formation. In sickle cell crisis, the primary issue is the obstruction of blood flow by sickled cells, not the formation of clots. Administering heparin may not address the underlying problem and can lead to potential complications.
Choice E rationale:
Replacement of factor VIII is not relevant to vaso-occlusive sickle cell crisis. Factor VIII is a protein involved in blood clotting and is primarily used in the treatment of hemophilia, a different condition unrelated to sickle cell crisis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Weighing the infant every day on the same scale at the same time is crucial in monitoring excess fluid volume in congestive heart failure. Sudden weight gain can indicate fluid retention, a common sign of worsening heart failure. Daily weight monitoring helps in early detection and timely intervention.
Choice B rationale:
Notifying the physician when weight gain exceeds more than 20 g/day might be too late for intervention. Daily weight monitoring is essential to detect trends and intervene promptly to manage excess fluid volume.
Choice C rationale:
Placing the infant in a car seat to minimize movement is not directly related to managing excess fluid volume in congestive heart failure. It is essential for safety during transportation but does not address the nursing diagnosis.
Choice D rationale:
Administering digoxin as ordered by the physician is a medical intervention for congestive heart failure. While important, the nursing diagnosis is related to excess fluid volume, and the focus should be on nursing interventions such as monitoring daily weights.
Correct Answer is A
Explanation
Choice A rationale:
The symptoms described by the baby's father, including confusion and having conversations with herself, are concerning and could indicate a severe mental health issue or a neurological problem. Urgent evaluation in an emergency room is necessary to rule out any acute medical or psychiatric condition that could be causing these symptoms. This is crucial for ensuring the safety and well-being of both the mother and the newborn.
Choice B rationale:
Bringing the wife to the office for medication is not appropriate in this situation without a proper evaluation. The symptoms described are severe and require immediate attention in an emergency room setting, where comprehensive assessments can be conducted.
Choice C rationale:
Outpatient care is not suitable for the described symptoms. The mother's confusion and hallucinations suggest a severe condition that requires urgent evaluation in a controlled environment like an emergency room. Outpatient care might be considered after the initial assessment and stabilization, but the immediate concern is the acute nature of the symptoms.
Choice D rationale:
Behavioral therapy is not appropriate for the described
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