An adolescent was recently diagnosed with acne vulgaris and was prescribed tetracycline. Which of the following statements indicates that the client requires further education?

A. Assist with administering a blood transfusion. Blood transfusions are often necessary in sickle cell crisis to manage severe anemia and improve oxygen delivery to tissues. This action helps alleviate the symptoms of the crisis and prevent complications.

B. Withhold opioids to avoid dependence. Opioids are essential for managing the severe pain associated with sickle cell crises. Concerns about dependence should not prevent adequate pain management in an acute setting.

C. Encourage exercise. During a sickle cell crisis, rest is crucial to reduce oxygen demand and prevent further sickling of red blood cells. Exercise is contraindicated during a crisis.

D. Initiate a 2 L/day fluid restriction. Adequate hydration is critical in managing sickle cell crisis, as it helps prevent further sickling of cells. Fluid restriction is inappropriate and could worsen the condition.

Increased seizure activity

• Finding: Phenytoin level

The child's phenytoin level is 6 mcg/mL, which is below the therapeutic range of 10-20 mcg/mL. Subtherapeutic levels of phenytoin mean the medication is not providing adequate seizure control, increasing the risk of more seizures. The recent seizure history and the low drug level indicate a direct correlation between insufficient phenytoin levels and increased seizure activity.

Pneumonia

• Finding: Cough

A harsh, non-productive cough that worsens with activity and at night can be indicative of respiratory conditions, including asthma exacerbations. However, in the context of this child's history and symptoms, there is no evidence of a productive cough, fever, or other signs of infection that would typically suggest pneumonia. Hence, pneumonia is not the primary concern.

Liver failure

• Finding: Skin rash

Liver failure is usually associated with jaundice, elevated liver enzymes, and systemic symptoms like fatigue or confusion. The child’s liver function tests are within normal ranges, and there are no signs of jaundice or systemic illness. The skin rash is more likely related to eczema or a possible drug reaction rather than indicating liver failure.

Steven-Johnson syndrome

• Finding: Liver enzymes

Steven-Johnson syndrome (SJS) is a severe skin reaction typically triggered by medications, including anticonvulsants. Elevated liver enzymes can be seen in SJS, but the child’s liver enzymes are within normal ranges. The rash described does not match the characteristics of SJS, which typically presents with widespread, painful, blistering rashes, not localized eczema patches. Therefore, SJS is unlikely in this scenario.

Pneumothorax

• Finding: Lung sounds

A pneumothorax would usually present with decreased breath sounds, possibly on one side, along with signs of respiratory distress such as tachypnea and cyanosis. The child has slight end expiratory wheezes but normal respiratory rates and oxygen saturation, which suggests asthma rather than pneumothorax. Therefore, pneumothorax is not a primary concern here.