An adolescent hospitalized with sickle cell anemia reports to the nurse of experiencing a pain level of 10 on a 0 to 10 numerical scale. The nurse observes the adolescent on a phone call laughing. Which action should the nurse take?

Introduce non-pharmacologic strategies for pain reduction.

Allow adequate privacy and time for the client's phone call.

Document the concern of incongruent pain rating and behavior.

Administer pain medication per the healthcare provider's orders.

Answer and Explanation

The Correct Answer is B

Choice A: Introducing non-pharmacologic strategies for pain reduction is a valid intervention for managing pain in a client with sickle cell anemia. However, in this scenario, the client's laughter on the phone call may not necessarily indicate that the pain level is accurately reflected by the numerical rating. It is essential to consider the client's overall well-being and pain management plan.

Choice B: Allowing adequate privacy and time for the client's phone call is a considerate and appropriate action. It acknowledges the client's need for communication and emotional support, which can be important in managing pain.

Choice C: Documenting the concern of incongruent pain rating and behavior is a necessary step for the nurse to record the observation. However, it should not be the only action taken in response to the situation.

Choice D: Administering pain medication should be based on a comprehensive assessment of the client's pain and the healthcare provider's orders. While pain medication may be indicated for this client, it should not be administered solely based on the numerical pain rating without further assessment and consideration of the client's overall condition.

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Correct Answer is B

Explanation

Choice A: Oranges are a good source of vitamin C, which is important for overall health, but they are not the primary dietary source for preventing rickets.

Choice B: Fortified milk is the best dietary source for preventing rickets because it is enriched with vitamin D, which is essential for calcium absorption and bone health. Vitamin D helps prevent rickets by promoting the absorption of calcium and phosphate in the body, which are necessary for proper bone development.

Choice C: Bananas are a good source of potassium but are not a primary dietary source for preventing rickets.

Choice D: Apple juice is not a primary dietary source for preventing rickets. While it may provide some vitamins and minerals, it is not directly associated with preventing this condition.

A. Weight loss history and body surface area (BSA). B. Body mass index (BMI) and serum albumin level. C. Triceps skin fold and mid-arm circumference. D. 24-hour food recall, food preferences, and allergies.

Correct Answer is B

Explanation

Choice A: Weight loss history and body surface area (BSA) are relevant factors to consider when assessing nutritional status, but they are not the most indicative parameters on their own.

Choice B: Body mass index (BMI) and serum albumin level are two of the most indicative parameters for assessing nutritional status. BMI provides information about body weight relative to height, while serum albumin level is a common marker of nutritional status and protein intake.

Choice C: Triceps skinfold and mid-arm circumference are anthropometric measurements that can provide additional information about muscle and fat stores in the body, but they are not as widely used or as indicative as BMI and serum albumin level.

Choice D: 24-hour food recall, food preferences, and allergies are important to assess but do not provide immediate indicators of nutritional status. They are valuable for understanding dietary habits and preferences.

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An adolescent hospitalized with sickle cell anemia reports to the nurse of experiencing a pain level of 10 on a 0 to 10 numerical scale. The nurse observes the adolescent on a phone call laughing. Which action should the nurse take?

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In conducting community health teaching, the nurse plans to describe foods that will help prevent rickets. What food product should the nurse recommend as the best dietary source for preventing rickets?

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