Unit 3: NR328 - Nursing care: sickle cell anemia
A newly-married couple, who are both carriers of the sickle cell trait, ask what the risk is of their children having sickle cell anemia. What is the best response by the nurse?
"Each child would have a 25% chance of having the disease."
The nurse has just admitted a client with sickle cell crisis. What is the nurse's highest priority action at this time?
Increasing fluid intake
Based on the client's initial physical assessment findings, the nurse anticipates receiving client specific orders from the healthcare provider. For each potential nursing action in the left column, specify if it is indicated, nonessential, or contraindicated for this client.
Indicated - Insert peripheral intravenous line Promote rest Provide analgesics Nonessential - child life consultation Contraindicated - Ice packs as non-pharmacological pain management
A child with sickle cell anemia comes to the emergency department for evaluation. The nurse suspects that the child is experiencing a vaso-occlusive crisis based on assessment of which signs and symptoms? Select all that apply.
Low back pain Distended abdomen Fever
In a child diagnosed with sickle cell disease, which clinical manifestations would the nurse most likely see? Select all that apply.
Pain, Pallor, hands and feet cool to the touch
A registered nurse (RN) is working with a licensed practical nurse (PN) who is caring for a 10-year-old who has severe abdominal, hip, and knee pain caused by a sickle cell crisis. Which action taken by the PN requires immediate intervention?
Positioning cold packs on the client's knees
For each client finding below, click to specify if the finding is consistent with sickle cell anemia, iron-deficiency anemia, or hemophilia. Each finding may support more than 1 disease process. Note: Each column must have at least 1 response option selected.
SCA - ALL IDA - fatigue, pallor Hemophilia - headache, pain
Select the 4 findings that require immediate attention.
Sensitive to light 2-week history of worsening headache Tingling in right side of face, right arm and leg 2-day history of diffuse back pain
The nurse is instructing the caregivers of a child with sickle cell anemia. What should the nurse emphasize during this teaching?
Ensure a consistent and daily intake of adequate fluids to prevent dehydration
A nurse is caring for a newly admitted pediatric client. Place the nursing action steps in the correct order for the proper care of a client with sickle cell.
1.) assess the pain 2.) believe the childs report of pain 3.) look for complications or cause of pain 4.) administer fluids 5.) give pain medications and use distraction 6.) provide rest in a quiet area
The nurse should address the client's --- followed by the client's---
deficient fluid volume, pain
The nurse has received orders from the healthcare provider. Select the 3 orders that the nurse should perform right away.
Administer D5 ½ normal saline (NS) with 10 mEq potassium chloride (KCl) at 110 ml/hr Morphine (pf) 1 mg/mL injection 4 mg Frequency: every 2 hours as needed (PRN) Route: intravenous (IV) Administer 1 unit packed red blood cells (PRBCs)
After teaching the caregivers of a child diagnosed with sickle cell disease, the nurse determines that the teaching was successful when the caregivers state that they will contact the primary health care provider if the child develops which signs or symptoms? Select all that apply.
chest pain sudden change in vision severe dizziness
The nurse is caring for a pediatric client with sickle cell anemia. Which assessment data is consistent with the clinical manifestations of sickle cell anemia?
expected - cool extremities, chest pain, fatigue, yellow sclera, priapism, pallor, dizziness unexpected - increased appetite, frontal bossing, depigmented areas on the abdomen
Based on the client's most recent physical assessment findings in the left column specify if it reflects an improvement, no change, or decline in the client's status.
improvement - Pain Pulses Tingling, numbness on right side Vital signs No change - LOC
A nurse is teaching the parents of a child with sickle cell disease about factors that predispose the child to a sickle cell crisis. The nurse determines that the teaching was successful when the parents identify what as a factor?
infection
