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 C
Explanation
Choice A rationale
Coughing and shortness of breath in the morning are signs of poor asthma control, not well- controlled asthma. These symptoms indicate that the child’s asthma is not being managed effectively and may require adjustments in their treatment plan.
Choice B rationale
This statement is incorrect. If asthma is not controlled, the child is likely to miss more days of school due to asthma symptoms and exacerbations. Effective asthma management aims to reduce symptoms and prevent asthma attacks, allowing the child to attend school regularly.
Choice C rationale
Eliminating allergens that irritate the lungs is a key strategy in preventing asthma attacks. Allergens such as dust mites, pet dander, mold, and pollen can trigger asthma symptoms. By reducing exposure to these allergens, the child can better manage their asthma and reduce the frequency of attacks.
Choice D rationale
This statement is false. Children with well-controlled asthma can participate in sports and physical activities. Physical activity is beneficial for lung function and overall health. The nurse should teach the child how to prevent exercise-induced asthma symptoms, such as using a bronchodilator before exercise.
Correct Answer is D
Explanation
Choice A rationale
Talking to the baby each day at a special time can help build a bond and promote language development. However, it is not the most important factor in promoting the infant’s development of trust. Consistent and responsive caregiving is more crucial in building trust.
Choice B rationale
Having many caregivers caring for the baby can lead to inconsistency in caregiving. According to Erikson’s theory of psychosocial development, infants need consistent and reliable caregiving to develop a sense of trust. Multiple caregivers can create confusion and insecurity for the baby.
Choice C rationale
Stimulating the baby with many toys can promote cognitive and motor development. However, it is not the most important factor in promoting the infant’s development of trust. Consistent and responsive caregiving is more crucial in building trust.
Choice D rationale
Responding to the baby’s needs consistently is the most important factor in promoting the infant’s development of trust. According to Erikson’s theory, infants develop trust when their caregivers are reliable and responsive to their needs. This consistent caregiving helps the baby feel secure and builds a foundation for healthy emotional development. .