A school-aged child is admitted to the hospital with a vaso-occlusive sickle cell crisis. Which measure in the child’s care plan should be given priority?
Encouraging the child to take deep breaths hourly.
Maintaining fluids through an intravenous line.
Beginning active range-of-motion exercises.
Seeing that the child ingests a protein-rich diet.
The Correct Answer is B
Choice A rationale
Encouraging deep breaths hourly can help prevent atelectasis and improve oxygenation, but it is not the priority in managing a vaso-occlusive crisis. The primary issue in a vaso-occlusive crisis is the blockage of blood flow due to sickled cells, leading to pain and potential organ damage. While deep breathing exercises are beneficial, they do not directly address the underlying cause of the crisis.
Choice B rationale
Maintaining fluids through an intravenous line is crucial in managing a vaso-occlusive crisis. Hydration helps to reduce blood viscosity, which can prevent further sickling of red blood cells and improve blood flow. Adequate hydration is essential to minimize the risk of complications such as stroke, acute chest syndrome, and organ damage. Therefore, maintaining IV fluids is a priority intervention in this scenario.
Choice C rationale
Beginning active range-of-motion exercises can help prevent joint stiffness and maintain mobility, but it is not the priority during an acute vaso-occlusive crisis. The primary focus should be on managing pain, ensuring adequate hydration, and preventing complications. Once the acute phase is managed, physical therapy and exercises can be introduced to support long- term health and mobility.
Choice D rationale
Seeing that the child ingests a protein-rich diet is important for overall health and growth, especially in children with chronic conditions like sickle cell anemia. However, during an acute vaso-occlusive crisis, the immediate priority is to manage pain, ensure hydration, and prevent complications. Nutritional support can be addressed once the acute crisis is under control.
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Correct Answer is B
Explanation
Choice A rationale
Mummy restraints, also known as swaddling, involve wrapping the infant’s body in a blanket to restrict movement. While this method can be used to calm and secure infants during certain procedures, it is not appropriate for postoperative care following cleft lip and palate repair. Mummy restraints do not prevent the infant from touching the surgical site and may cause discomfort.
Choice B rationale
Elbow restraints are the appropriate choice for an infant postoperative following cleft lip and palate repair. These restraints prevent the infant from bending their arms and touching or damaging the surgical site. Elbow restraints allow for some movement and circulation while ensuring the surgical area remains protected during the healing process. They are commonly used in pediatric postoperative care to prevent self-injury.
Choice C rationale
Jacket restraints involve securing the infant’s torso to prevent movement. While jacket restraints can be used in certain situations to ensure safety, they are not suitable for postoperative care following cleft lip and palate repair. Jacket restraints do not specifically prevent the infant from touching the surgical site and may cause unnecessary restriction and discomfort.
Choice D rationale
Wrist restraints involve securing the infant’s wrists to prevent movement. While wrist restraints can be used to prevent self-injury, they are not the best choice for postoperative care following cleft lip and palate repair. Wrist restraints may not effectively prevent the infant from reaching the surgical site and can cause discomfort and distress. .
Correct Answer is D
Explanation
Choice A rationale
A storybook about a child who has diabetes can be helpful in educating the child about their condition and normalizing their experience. However, it may not be as effective in addressing the immediate distress caused by an insulin injection. Therapeutic play that directly involves the injection experience can be more beneficial in helping the child cope with their fear and anxiety.
Choice B rationale
A period of play in the playroom can provide a distraction and help the child relax. However, it does not specifically address the child’s distress related to the insulin injection. Therapeutic play that involves role-playing the injection process can be more effective in helping the child understand and cope with the procedure.
Choice C rationale
A video game can serve as a distraction and help the child relax. However, it does not directly address the child’s fear and anxiety related to the insulin injection. Therapeutic play that involves role-playing the injection process can be more effective in helping the child understand and cope with the procedure.
Choice D rationale
Using a needleless syringe and a doll allows the child to engage in therapeutic play that simulates the experience of receiving an insulin injection. This type of play helps the child understand the procedure, reduces fear and anxiety, and provides a sense of control over the situation. It is a direct and effective way to help the child cope with the distress caused by the injection.