The nurse is caring for a 14-year-old child who is in a sickle cell crisis and has severe pain. Which nursing intervention is the most appropriate for this child?

Administer non-opioid analgesics.

Use guided imagery to prepare the child for painful procedures.

Suggest diversional activities, such as coloring.

Request an order to start an IV PCA.

Answer and Explanation

The Correct Answer is D

Choice A reason: Non-opioid analgesics are typically not strong enough to manage the severe pain associated with a sickle cell crisis.
Choice B reason: Guided imagery can be a helpful adjunct, but it is not the primary method of pain control during a crisis.
Choice C reason: Diversional activities may help distract from the pain but are not sufficient as the sole method of pain management.
Choice D reason: This is the correct choice. An IV PCA (patient-controlled analgesia) allows the child to manage pain effectively and is appropriate for severe pain during a sickle cell crisis.

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Correct Answer is D

Explanation

Choice A reason: A high-pitched cry can be a sign of distress in an infant, but it is not a specific indicator of increased intracranial pressure. It could be due to a variety of reasons, including discomfort, hunger, or other forms of distress.
Choice B reason: Decreased lower extremity movement could be a sign of a neurological issue, but it is not a direct indicator of increased intracranial pressure. It would require further evaluation to determine the cause.
Choice C reason: Excessive wet diapers are not typically associated with increased intracranial pressure. This symptom could be related to other conditions such as diabetes insipidus or excessive fluid intake.
Choice D reason: This is the correct choice. A bulging fontanel when crying is a classic sign of increased intracranial pressure in an infant. The fontanel, or soft spot on the baby's head, can bulge when there is increased pressure within the skull. This should be promptly evaluated by a healthcare professional.

A. Note the frequency of drooling. B. Observe the appearance of oral mucosa. C. Assess patterns of speech. D. Determine the ability to chew and swallow.

Correct Answer is D

Explanation

Choice A reason: While noting the frequency of drooling is important, it is not the most critical assessment.
Choice B reason: Observing the appearance of oral mucosa is less critical than assessing the ability to swallow.
Choice C reason: Assessing speech patterns is important but secondary to swallowing ability in terms of immediate safety.
Choice D reason: This is the correct choice. The ability to chew and swallow is crucial for preventing aspiration and maintaining nutrition.

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The nurse is caring for a 14-year-old child who is in a sickle cell crisis and has severe pain. Which nursing intervention is the most appropriate for this child?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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