The nurse is assessing a school-aged child with sickle-cell anemia. Which assessment finding is consistent with this child’s diagnosis?
Slightly yellow sclera.
Depigmented areas on the abdomen.
Enlarged mandibular growth.
Increased growth of long bones.
The Correct Answer is A
Choice A rationale
Slightly yellow sclera, or jaundice, is a common finding in children with sickle cell anemia. The breakdown of sickled red blood cells leads to increased bilirubin levels in the blood, which can cause jaundice. This yellowing is often most noticeable in the sclera of the eyes. Jaundice is a result of hemolysis, a hallmark of sickle cell anemia, where red blood cells are destroyed faster than they can be produced.
Choice B rationale
Depigmented areas on the abdomen are not typically associated with sickle cell anemia. Sickle cell anemia primarily affects the blood and organs, leading to complications such as pain crises, anemia, and organ damage. Skin changes like depigmentation are not characteristic of this condition and may indicate other underlying issues.
Choice C rationale
Enlarged mandibular growth is not a common finding in sickle cell anemia. While children with sickle cell anemia may experience growth delays and skeletal abnormalities due to chronic anemia and bone marrow hyperactivity, mandibular enlargement is not a typical feature. Skeletal changes in sickle cell anemia are more likely to involve long bones and vertebrae.
Choice D rationale
Increased growth of long bones is not a characteristic finding in sickle cell anemia. In fact, children with sickle cell anemia may experience growth delays and shorter stature due to chronic anemia and the body’s increased demand for red blood cell production. The condition can lead to skeletal abnormalities, but these typically involve bone infarctions and deformities rather than increased growth.
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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 B
Explanation
Choice A rationale
Notifying the health care provider immediately may be necessary if the bleeding is severe or persistent. However, in the case of small amounts of blood, it is important to continue assessing for bleeding to determine if the situation worsens. Immediate notification may not be necessary for minor bleeding.
Choice B rationale
Continuing to assess for bleeding is the best intervention for a child spitting up small amounts of blood after a tonsillectomy. This allows the nurse to monitor the situation and determine if the bleeding is worsening or if it resolves on its own. It is important to keep the child calm and avoid any actions that could exacerbate the bleeding.
Choice C rationale
Encouraging the child to cough can increase the risk of further bleeding. Coughing can dislodge clots and cause additional trauma to the surgical site. It is important to keep the child calm and avoid actions that could worsen the bleeding.
Choice D rationale
Suctioning the back of the throat can cause additional trauma to the surgical site and increase the risk of bleeding. It is important to avoid invasive procedures and continue to assess for bleeding. If the bleeding worsens, further medical intervention may be necessary.