An 11-year-old patient with sickle cell anemia is admitted to the hospital with vaso-occlusive crisis. He is experiencing pain in his left elbow. The nurse needs to monitor the patient for which symptom?
Ketonuria.
Diplopia.
Severe abdominal pain.
Hyperactive patellar reflex.
The Correct Answer is D
Choice A rationale:
Ketonuria is the presence of ketones in urine and is not directly associated with vaso-occlusive crisis in sickle cell anemia. This crisis typically involves pain and ischemia in various body parts.
Choice B rationale:
Diplopia refers to double vision and is not a typical symptom of vaso-occlusive crisis. Pain, not vision changes, is the primary concern in this scenario.
Choice C rationale:
Severe abdominal pain can be a symptom of vaso-occlusive crisis in sickle cell anemia, but the patient's complaint of left elbow pain would not directly correlate with this choice.
Choice D rationale:
Hyperactive patellar reflex is the correct answer. During vaso-occlusive crisis, the body's response to pain can lead to increased muscle tone and reflexes, including hyperactive deep tendon reflexes like the patellar reflex. This is an indicator of neurologic involvement in the crisis. Remember that these rationales are intended to provide a concise understanding of the correct answers based on the information provided in the questions. Always refer to medical literature and consult with healthcare professionals for comprehensive and accurate information.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Instructing the mother in palpation of bladder distention might not effectively address the issue of incomplete bladder emptying. Clean intermittent catheterization is a more appropriate technique to ensure complete emptying.
Choice B rationale:
Informing the mother that life-long antibiotic administration will be necessary is not the primary approach. Antibiotics may be required in specific situations, but addressing incomplete emptying is the key focus.
Choice C rationale:
Preparing the mother for the need for urinary diversion surgery is premature. Clean intermittent catheterization is a conservative measure that should be attempted before considering surgical options.
Choice D rationale:
Instructing the mother in the technique of clean intermittent catheterization helps manage the neurogenic bladder's incomplete emptying. This technique reduces the risk of urinary tract infections and promotes bladder health.
Correct Answer is D
Explanation
Choice D rationale:
Monitoring the cardiac catheterization site for bleeding is the priority nursing intervention when a child feels nauseous and vomits after a cardiac catheterization. Bleeding from the catheterization site could lead to serious complications and requires immediate attention.
Choice A rationale:
Applying a cool cloth to the child's forehead can provide comfort, but it doesn't address the potential complication of bleeding from the catheterization site.
Choice B rationale:
Offering the child sips of orange juice is not appropriate if the child is nauseous and vomiting. Fluid intake should be monitored, but bleeding assessment takes priority.
Choice C rationale:
Applying pressure to the cardiac catheterization site is not the priority intervention. Monitoring for bleeding and assessing the site are more important.
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