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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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. .
Correct Answer is D
Explanation
Choice A rationale
Polyuria, or excessive urination, is typically associated with hyperglycemia rather than hypoglycemia. In the context of diabetes, polyuria occurs when high blood glucose levels lead to increased urine production as the body attempts to excrete excess glucose. Since the adolescent’s blood glucose level is 55 mg/dL, which indicates hypoglycemia, polyuria is not an expected finding.
Choice B rationale
Dry, flushed skin is a common symptom of hyperglycemia, not hypoglycemia. When blood glucose levels are high, the body becomes dehydrated, leading to dry skin and a flushed appearance. In contrast, hypoglycemia often presents with symptoms such as sweating, pallor, and shakiness due to the body’s response to low blood glucose levels.
Choice C rationale
Deep, rapid respirations, also known as Kussmaul respirations, are typically associated with diabetic ketoacidosis (DKA), a complication of hyperglycemia. DKA occurs when the body produces high levels of ketones due to insufficient insulin. Since the adolescent’s blood glucose level is 55 mg/dL, which indicates hypoglycemia, deep, rapid respirations are not an expected finding.
Choice D rationale
Tachycardia, or an increased heart rate, is a common symptom of hypoglycemia. When blood glucose levels drop, the body releases catecholamines (such as adrenaline) to raise blood glucose levels. This response leads to symptoms such as shakiness, sweating, and tachycardia. Therefore, tachycardia is an expected finding in an adolescent with a blood glucose level of 55 mg/dL.