Nokea
A child is admitted in sickle cell crisis. Which factor in the child's history is most likely related to the onset of the crisis?
- A. The child just completed final exams at school.
- B. The child ran a marathon yesterday.
- C. The child recently had a cold.
- D. The child received a hepatitis A immunization two weeks ago.
Correct Answer: C
Rationale: Infections, like a recent cold, can trigger sickle cell crisis by increasing oxygen demand and causing dehydration, leading to sickling of red blood cells.
You may also like to solve these questions
The nurse is caring for a client with a deep vein thrombosis. Which finding would require the nurse's immediate attention?
- A. Temperature of 102 degrees Fahrenheit
- B. Pulse rate of 98 beats per minute
- C. Respiratory rate of 32
- D. Blood pressure of 90/50
Correct Answer: C
Rationale: Respiratory rate of 32. Clients with deep vein thrombosis are at risk for the development of pulmonary embolism (PE). The most common symptoms of PE are tachypnea, dyspnea, and chest pain.
A client with a marked depression of T cells.
To promote safety in the environment of a client with a marked depression of T cells, the nurse should
- A. keep a linen hamper immediately outside the room.
- B. restrict eating utensils to spoons made of plastic.
- C. provide masks for anyone entering the room.
- D. remove any standing water left in containers or equipment.
Correct Answer: D
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) protocol for handling soiled articles is accomplished within universal guidelines with double biohazard bags (2) universal precautions and client protection may call for plastic utensils, but not just spoons (3) not protocol unless the client has an active pulmonary infection (4) correct-water should not be allowed to stand in containers, such as respiratory or suction equipment, because this could act as a culture medium
The nurse is caring for clients on the neurology unit.
- A. What is the most appropriate action for the nurse to take after noting a client suddenly developed a fixed and dilated pupil?
- B. Reassess in five minutes.
- C. Check the client’s visual acuity.
- D. Lower the head of the client’s bed.
- E. Contact the physician.
Correct Answer: D
Rationale: A fixed and dilated pupil is a neurological emergency, often indicating increased intracranial pressure or brain herniation. Immediate physician notification is critical to initiate interventions. Reassessing later delays care, checking visual acuity is irrelevant, and lowering the bed could worsen intracranial pressure.
The nurse is caring for a client who is postoperative day 1 after a prostatectomy. Which of the following findings should the nurse report immediately?
- A. Mild pain at the incision site.
- B. Temperature of 100.8°F (38.2°C).
- C. Blood-tinged urine.
- D. Urine output of 200 mL/hour.
Correct Answer: B
Rationale: A temperature of 100.8°F suggests infection, a serious post-prostatectomy complication. Options A, C, and D are normal.
An elderly client with osteoarthritis.
The homecare nurse is visiting an elderly client with osteoarthritis. It would be MOST important for the nurse to include which of the following instructions?
- A. Swimming is the only helpful exercise for osteoarthritis.
- B. Warm-up exercises should be done prior to exercising.
- C. Exercises should be done routinely, even if severe joint pain occurs.
- D. Isometric exercises are most helpful to prevent contractures.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) swimming is only one helpful exercise (2) correct-warm-up or 'stretching' exercises should always be done to begin and end exercising (3) severely painful joints should not be exercised (4) isometric exercises do not involve joint movement