Nokea
A nurse is caring for a school-age child who has sickle cell anemia and is in vaso-occlusive crisis. Which of the following actions should the nurse take?
- A. Apply cold compresses to the affected areas.
- B. Prepare for a transfusion of platelets.
- C. Promote active range of motion exercises.
- D. Increase oral fluid intake.
Correct Answer: D
Rationale: The correct answer is D: Increase oral fluid intake. During a vaso-occlusive crisis in sickle cell anemia, there is a blockage of blood flow leading to tissue ischemia and pain. Increasing oral fluid intake helps to hydrate the child and improve blood flow, potentially reducing the severity of the crisis. Cold compresses (A) can worsen vasoconstriction, platelet transfusion (B) is not indicated for vaso-occlusive crisis, and active range of motion exercises (C) can exacerbate pain and further compromise blood flow. Increasing fluid intake is the most appropriate intervention to help manage the crisis.
You may also like to solve these questions
A nurse on the pediatric unit is admitting the child from the emergency department. For each of the assessment finding below, click to specify if the assessment finding is consistent with Kawasaki disease, scarlet fever, or rheumatic fever. Each finding may support more than 1 disease process of none at all. There must be at least 1 selection in every column. There does not need to be a selection in every row.
- A. Recent diagnosis of pharyngitis.
- B. Nodules
- C. Cardiomegaly
- D. Polyarthralgia
Correct Answer: A,B,C,D
Rationale: The correct answer is .
A: Recent diagnosis of pharyngitis - Consistent with all three diseases as pharyngitis can be a symptom in Kawasaki disease, scarlet fever, and rheumatic fever.
B: Nodules - Can be seen in Kawasaki disease (cervical lymphadenopathy), scarlet fever (subcutaneous nodules), and rheumatic fever (subcutaneous nodules).
C: Cardiomegaly - Seen in Kawasaki disease (coronary artery aneurysms), scarlet fever (cardiomegaly due to myocarditis), and rheumatic fever (cardiomegaly due to carditis).
D: Polyarthralgia - Present in Kawasaki disease (arthritis), scarlet fever (arthritis), and rheumatic fever (migratory arthritis).
Therefore, all these assessment findings can be associated with Kawasaki disease, scarlet fever, and rheumatic fever.
A nurse is assessing a 2-year-old toddler. Which of the following findings should the nurse expect?
- A. Head circumference exceeds chest circumference
- B. Nontender, protruding abdomen
- C. Natural loss of deciduous teeth
- D. Palpable fontanels
Correct Answer: B
Rationale: The correct answer is B: Nontender, protruding abdomen. In toddlers, it is normal to have a nontender, protruding abdomen due to the physiological characteristics of their developing digestive system and musculature. This is because toddlers have less developed abdominal muscles and a larger liver in proportion to their body size, causing their abdomen to appear slightly distended. This finding is considered normal and does not typically indicate any underlying health issues. The other options are incorrect because: A: Head circumference exceeding chest circumference is not a typical finding in a 2-year-old toddler. C: Natural loss of deciduous teeth typically occurs around age 6-7, not in toddlers. D: Fontanels should be closed by 18 months, so palpable fontanels in a 2-year-old would be abnormal.
A nurse in an emergency department is caring for a 3-year-old child who has suspected epiglottitis. Which of the following actions should the nurse take?
- A. Prepare to assist with intubation.
- B. Obtain a throat culture.
- C. Suction the child's oropharynx.
- D. Prepare a cool mist tent.
Correct Answer: A
Rationale: The correct answer is A: Prepare to assist with intubation. Epiglottitis is a medical emergency that can cause rapid airway obstruction. Intubation ensures a secure airway and oxygenation. Throat culture (B) is not a priority in this acute situation. Suctioning (C) can provoke spasm and worsen obstruction. Cool mist tent (D) does not address the immediate need for securing the airway.
A nurse in an emergency department is caring for a 3-year-old child who has suspected epiglottitis. Which of the following actions should the nurse take?
- A. Prepare to assist with intubation.
- B. Obtain a throat culture.
- C. Suction the child's oropharynx.
- D. Prepare a cool mist tent.
Correct Answer: A
Rationale: The correct answer is A: Prepare to assist with intubation. Epiglottitis is a medical emergency where the epiglottis becomes inflamed and can lead to airway obstruction. Intubation may be necessary to secure the airway and ensure the child can breathe. It is a priority action to maintain the child's oxygenation and ventilation. Obtaining a throat culture (B) can be important for diagnosis but is not the immediate priority. Suctioning the child's oropharynx (C) can trigger a spasm and worsen the obstruction. Cool mist tent (D) is not indicated in the management of epiglottitis.
A nurse in a clinic is planning care for a child who has ADHD and is taking atomoxetine. Which of the following laboratory values should the nurse monitor?
- A. Liver function tests
- B. Kidney function tests
- C. Hemoglobin and hematocrit
- D. Serum sodium and potassium
Correct Answer: A
Rationale: The correct answer is A: Liver function tests. Atomoxetine, used for ADHD, can potentially cause liver toxicity. Monitoring liver function tests helps detect any signs of liver damage early on. Choice B, kidney function tests, is not as relevant as atomoxetine primarily affects the liver. Choice C, hemoglobin and hematocrit, is not directly impacted by atomoxetine. Choice D, serum sodium and potassium, is not typically affected by atomoxetine use.