HESI CS - Sicle Cell Anemia

What is the total intake for this shift, in mL? (Enter the numerical value only. If rounding is necessary, round to the whole number.)

1920

Which recommendation about immunization should the school nurse make to the child's caregiver? a. The child needs her second scheduled dose of MMR #2. b. The child is current with her immunizations. c. The child needs her Hepatitis A immunizations. d. The child needs her influenza vaccine.

A According to current immunization schedules, she should have had two scheduled doses of MMR, with the second due at 4 to 6 years of age.

Which statement by the child indicates she is meeting Erikson's stage of development for her age? a. "Look, I finished putting the puzzle together." b. "I don't want any of my friends to visit me here." c. "I need my stuffed dog so that I can go to sleep." d. "When I grow up, I want to be a nurse just like you."

A School-aged children are in Erikson's stage of developing a sense of industry, meaning they like to do and accomplish things.

Which nursing task is best for the charge nurse to delegate to the UAP? a. Take the hourly vital signs for a child receiving a unit of blood. b. Teach the child's caregiver how to apply warm soaks to her joints. c. Educate the child about a healthy lifestyle. d. Change the morphine vial on the client-controlled analgesia pump.

A The UAP can take the vital signs but the RN must evaluate the results.

Which action should the emergency department (ED) nurse implement first? a. Request arterial blood gasses stat. b. Administer oxygen via nasal cannula. c. Send the child for an x-ray of her knees and elbows. d. Prepare to administer analgesics as prescribed.

B A pulse oximeter reading of less than 93% indicates hypoxia, which warrants oxygen administration. Oxygen will not help reverse the sickling crisis because oxygen cannot reach the enmeshed sickled erythrocytes in clogged vessels. However, it will help oxygenate the cells that are not sickled.

What is the best response by the nurse? a. "I will get the HCP to explain why the vaccines are needed." b. "She is susceptible to infections. These vaccinations may help prevent a crisis." c. "These vaccines are required for all children younger than 10 years of age." d. "I know you don't like to see her hurt, but she must have these vaccines."

B An individual with SCD has a functional reduction in splenic activity, which progresses to the point at which the spleen is no longer able to function. This increases susceptibility to infection.

Which is the best initial response by the nurse? a. "When your daughter gets a fever give her 1 baby aspirin." b. "Keep her away from anyone who has an infection." c. "There is no way you can make sure this never happens again." d. "Make sure she does not participate in any strenuous activity."

C A child with sickle cell anemia will experience crises. The caregiver needs to understand that she cannot prevent a crisis from ever happening again. The nurse should provide instructions about measures to reduce the frequency of crises, as well as how to recognize crises when they do occur.

Which statement is the best response by the nurse? a. "You sound like you are worried about taking your daughter home." b. "I recommend enrolling her in a sport with running, such as soccer." c. "School-aged children like being in groups like Girl Scouts or Girls' Clubs." d. "Your daughter should not be around a lot of children, so her activities will be limited."

C Formal organizations foster self-esteem and competence as children earn ranks and merit badges. Interaction with peers, acquisition of new skills, and a sense of belonging to a group outside the family can help increase self-esteem.

What is the best response by the nurse? a. "I know that she will enjoy meeting her family." b. "I think you should talk to her HCP before you go." c. "Your planned trip may put her at risk for a crisis." d. "Could your family come here for the Christmas holidays instead?"

C High altitudes have decreased oxygen, which could lead to a sickle cell crisis. In addition, cold will cause constriction of blood vessels, further decreasing the oxygen supply.

The nurse anticipates the prescription of which diagnostic test by the ED HCP (health care provider)? a. Peripheral blood smear. b. Hemoglobin electrophoresis. c. Sickle-turbidity test. d. Blood cultures.

D An elevated temperature is the first sign of bacteremia, which leads to a sickle cell crisis. The bacteria must be identified so the appropriate antibiotic can be prescribed to treat the infection.

Which behavior indicates to the nurse the caregiver understands about acute exacerbations of sickle cell anemia? a. She is able to take the child's radial pulse within 4 beats of the nurse. b. She does not allow her daughter to go outside unless she is with her. c. She measures her daughter's fluid intake to remain under 1 liter a day. d. She demonstrates how to accurately read an oral thermometer.

D An elevated temperature is the first sign of infection, which can, and many times does, lead to an acute exacerbation of SCD. Therefore, being able to take her daughter's temperature correctly is vital.

Which is the best initial response by the nurse to explain SCD to the child's caregiver? a. "I have some written material that will explain all about the disease." b. "It is a disease of the blood that requires taking medication every day." c. "Your daughter will probably have episodes of severe joint pain and will need to be hospitalized." d. "Red blood cells become 'C' shaped, stiff, and sticky, which blocks the blood vessels."

D Sickle cell anemia is a disorder of the red blood cells characterized by abnormally shaped red blood cells that block and damage blood vessels, leading to oxygen deprivation, pain, anemia, serious infections, and damage to vital organs.

Which action should the nurse implement? a. Notify the HCP immediately. b. Retake and assess the vital signs in 1 hour. c. Encourage the child to turn, cough, and deep breathe. d. Document the findings on the graphic sheet.

D These are normal vital signs for a 8-year-old child; pulse is 70 to 110 beats per minute, respirations 18 to 22 breaths per minute, blood pressure systolic: 83 to 121 and diastolic 45 to 79. The HCP will use a detailed breakdown of height by age norms to determine normal vs. hypertensive.

Which action should the nurse implement? a. Notify the HCP immediately. b. Explain that blood in the urine is expected. c. Request a stat hemoglobin level. d. Request a stat sterile urine specimen.

B Hematuria is an expected clinical manifestation during a vaso-occlusive sickle cell crisis.

After fluids have started, the child relates that her pain is an 8 on the Wong-Baker FACES pain scale. Which medication should the nurse expect to be prescribed for pain control? a. Morphine sulfate b. Ibuprofen. c. Acetaminophen. d. Meperidine.

A Opioids provide systemic relief for the child with sickle cell.

How should the nurse respond? a. "This disease is an inherited autosomal recessive disease and your daughter inherited the gene responsible for causing the disease." b. "Your daughter has the disease because she inherited the gene from one of her parents, who is a carrier." c. "She must have had a bad reaction to a transfusion as a child." d. "She was exposed to a virus while her caregiver was pregnant." Submit Previous Section

A SCD is an inherited autosomal recessive disease and the nurse needs to ensure that the family understands the medical terminology used. Autosomal recessive indicates that the disease was passed on by both parents.

Which intervention should be included in the care plan? a. Assess pain by using a numerical pain scale. b. Explain how to use a patient-controlled analgesic pump. c. Apply cold compresses periodically to painful joints. d. Administer acetaminophen PRN as needed for pain.

B Opioids are the mainstay for analgesic treatment for acute pain, and when they are administered via PCA pump the child has better control of the pain. Both the child and the caregiver should receive information about use of the PCA pump.

Which of the following statements by the caregiver should the nurse question? a. "We must make sure that she is staying hydrated to prevent another crisis." b. "Deep breathing should be adequate to relieve pain caused by sickle cell anemia." c. "There are support groups we can reach out to for moral support." d. "We should schedule breaks during activities because she can tire easily."

B Pain management is a key intervention for sickle cell patients and requires appropriate medication.

Which intervention should the nurse implement first? a. Change the bed linens. b. Help change her clothes. c. Find the child's caregiver in the cafeteria. d. Document the incident in the chart.

B The nurse should address physical needs first, then find her caregiver, have the bed linens changed, and document the incident. Enuresis is expected due to increased fluid intake.

Which potentially fatal complication(s) can occur? (Select all that apply.) a. Vaso-occlusive crisis. b. Cerebral vascular accident. c. Priapism. d. Hypertensive crisis. e. Heart failure.

B, E Due to the sickling of the blood and to tissue hypoxia, a cardiovascular accident (CVA) or stroke may occur and is potentially fatal. The patient with SCD can develop heart failure related to cardiomegaly.

Which orders should the nurse anticipate? Select all that apply. a. Provide the child with cold packs to place on her joints. b. Admit the child to a private room and keep her in reverse isolation. c. Intravenous fluids via infusion pump. d. Insert a 22 French indwelling urinary catheter with a urometer

C Increased intravenous fluid reduces the viscosity of blood, thereby preventing further sickling due to dehydration. This rate is higher than usual for a 8-year-old, but it is indicated during a sickle cell crisis.

Which child should the charge nurse assign to the new graduate nurse? a. A school-aged child newly diagnosed with cystic fibrosis. b. The child with sickle cell anemia who is scheduled as a probable discharge for tomorrow. c. A school-aged child who had an appendectomy 2 days ago. d. A school-aged child being evaluated for possible physical abuse.

C This child had a routine surgery. There is no data indicating that the child is unstable; therefore, a new graduate should be able to provide safe care for this child.

Which food should the nurse offer to the child who is in a sickle cell crisis? a. Peaches. b. Cottage cheese. c. Popsicles. d. Lima beans.

C This will improve the child's hydration status. Other select items are gelatin, juices, and puddings.

Which intervention should the nurse implement? a. Explain that the other children should be extra nice to the child. b. Instruct the teacher to have the child sit at the front of the classroom. c. Encourage the child to participate in all playground activities. d. Request the child be allowed to go to the bathroom whenever she asks.

D The child needs increased hydration to prevent a sickling crisis. This increased fluid intake will lead to increased urination, so it is important that she be allowed to go to the bathroom as needed.