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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View Related questions
Correct Answer is ["A","B","C","D"]
Explanation
A: This is the first step as it allows the nurse to gather information through observation without causing discomfort to the child. It involves looking at the child’s abdomen for any visible abnormalities like distension, asymmetry, masses, or discoloration.
B: This step follows inspection to assess bowel sounds before any manipulation of the abdomen, which could alter the sounds. The nurse listens for the presence, frequency, and character of bowel sounds.
C:This step is performed to assess for tenderness, muscle tone, and surface characteristics. It is done gently to avoid causing pain or discomfort.
D:This is the final step to assess for any masses, organomegaly, or deep tenderness. It is performed more firmly but should be done carefully to avoid causing pain.
Correct Answer is A
Explanation
Choice A rationale
Measuring head circumference every shift is unnecessary for a 6-year-old child with bacterial meningitis. This intervention is more relevant for infants where head circumference changes can indicate increased intracranial pressure.
Choice B rationale
Implementing seizure precautions is necessary as bacterial meningitis can cause seizures due to increased intracranial pressure and inflammation.
Choice C rationale
Admitting the client to a private room is necessary to prevent the spread of infection, as bacterial meningitis can be highly contagious.
Choice D rationale
Placing the client in a semi-Fowler’s position helps reduce intracranial pressure and promotes comfort.