Nurs. 128 Brittany Long Core Vsims Pre & Post Questions
A nurse is assessing the pain level of a 5-year-old patient hospitalized with vaso-occlusive pain crisis. Which pain scale would the nurse use to assess this patient? A) Visual analog scale B) FACES scale C) FLACC scale D) Numeric pain intensity scale (0 to 10)
B) FACES scale Rationale: The FACES pain rating scale is a self-report tool that is acceptable for use with a developmentally appropriate 5-year-old. Visual analog and numeric scales are for use with patients over 7 or 8 years of age. The FLACC behavioral scale is appropriate for when the patient cannot accurately report their own level of pain due to age or developmental level.
The nurse is caring for a patient weighing 16 kg with an order to administer acetaminophen (Tylenol) for acute pain crisis. The safe dosage range for children is 10 to 15 mg/kg/dose. What is the maximum safe dose for this patient in milligrams? __________
240 mg Rationale: To determine the maximum safe dose for this patient, multiply the high end of the dosage range by the patient's weight in kilograms: 15 × 16 = 240. Thus, the maximum safe dose is 240 mg.
The nurse uses developmentally appropriate care by ___________ when _____________.
allowing the child to assist with care, assessing vital signs Rationale: The nurse would allow Brittany to assist with care while performing simple procedures, such as vital signs assessment. Preschool children are concrete thinkers and therefore would not understand abstract or detailed explanations. The nurse would include Brittany in education and would not speak only to the caregiver. Concerns about personal appearance are common in adolescents, not preschoolers. It would not be appropriate for Brittany to assist with medication administration; school-age children can begin to self-administer some medications with direct supervision, but this is not an appropriate intervention for a preschool-age child. Only the nurse would perform a sterile dressing change or fluid rate adjustments.
A 5-year-old with a history of sickle cell anemia presents to the emergency room with acute leg pain. When obtaining the health history, the nurse should include questions related to which factor(s)? (Select all that apply.) A) Frequency of vaso-occlusive crises B) Precipitating events C) Past hospitalizations and treatment D) Family history of blood transfusions E) Immunization history
A) Frequency of vaso-occlusive crises B) Precipitating events C) Past hospitalizations and treatment E) Immunization history Rationale: When obtaining a health history on a patient with sickle cell anemia, the nurse should elicit information related to growth and development, frequency and extent of vaso-occlusive crises, past hospitalizations and treatment for pain crises, immunization history, personal history of blood transfusions, current medication regimen, and precipitating events. A family history of blood transfusions would not be relevant, as it would not affect the patient.
What other information is needed to plan care for Brittany? (Select all that apply.) A) Current pain level using the FLACC scale B) Allergies C) Medical history D) Urinary output E) Grade level F) Current weight
B) Allergies C) Medical history D) Urinary output F) Current weight Rationale: The nurse would need to know allergies, medical history, urinary output (to plan for fluid administration), and current weight (because medication doses are weight based in pediatrics). The FLACC (Face, Legs, Activity, Cry, Consolability) scale is used for infants and toddlers, not for preschoolers. The nurse would not need to know Brittany's grade level before providing care.
During the nurse's initial assessment of a 5-year-old child admitted with vaso-occlusive crisis, the patient reports a pain level of 8 on the FACES scale. The patient is lying quietly in bed watching television. Which action would the nurse take? A) Administer the prescribed analgesic as ordered. B) Ask the caregiver whether the patient is hurting. C) Reassess the patient in 15 minutes to see whether the pain rating has changed. D) Continue to monitor, because the patient appears to be resting
A) Administer the prescribed analgesic as ordered. Rationale: The FACES pain rating scale is a self-report tool that can be used by children as young as 3 years of age. A 5-year-old is old enough to accurately report their own pain level and may be lying still as a coping strategy or because movement is painful. Resting quietly or sleeping may be a coping strategy for the patient when experiencing pain or may reflect exhaustion in the patient who is coping with pain.
The nurse is performing a physical assessment on a 5-year-old patient. Which statement demonstrates that the nurse understands developmentally appropriate communication? A) "I want to listen to you breathe. I need you to help me hold my stethoscope in place." B) "I am going to take your temperature and blood pressure now." C) "You need to change into a hospital gown before I can examine you." D) "Your parent will need to wait outside while I complete your assessment."
A) I want to listen to you breathe. I need you to help me hold my stethoscope in place. Rationale: Preschoolers should be given a job during the assessment process, such as holding the stethoscope or pen light. The nurse should avoid using confusing terms such as temperature, blood pressure, or test. Instead, the nurse should say, "Let's see how warm you are" or "I want to listen to you breathe." When assessing a preschool-aged patient, the patient can sit in the caregiver's lap or sit on the exam table within reach and eye contact of the caregiver. Children should never be forced to change into a gown. It is important to allow children to stay in their own clothing and to wear shorts or underwear under a gown if preferred.
Which statement(s) by the caregiver indicate(s) that the education about sickle cell anemia has been effective? (Select all that apply.) A) "Brittany has only one abnormal hemoglobin gene." B) "It is important for Brittany to drink enough fluid." C) "Brittany has a higher red blood cell count than other children." D) "We will give acetaminophen whenever Brittany has a fever." E) "If Brittany has children, they will also have sickle cell disease." F) "The vaso-occlusive crises are very painful for Brittany."
B) "It is important for Brittany to drink enough fluid." D) "We will give acetaminophen whenever Brittany has a fever." F) "The vaso-occlusive crises are very painful for Brittany." Rationale: Dehydration, pain, fever, and illness can all trigger sickling and vaso-occlusive crises, so it is important for Brittany to drink enough fluid and for her fevers to be promptly treated. Parents should give acetaminophen to treat fever and should promptly treat any illnesses or infections. Vaso-occlusive crises deprive tissues of oxygen, causing ischemia and significant pain. Sickle cell disease occurs when a person inherits two abnormal hemoglobin (Hgb) genes instead of two normal adult Hgb (Hgb A) genes. Children with sickle cell disease have hemolytic anemia and a lower number of red blood cells than other children. The sickle cell traits are genetic, but a child must receive a sickle cell gene from both parents to have sickle cell disease.
When developing the plan of care for Brittany, which intervention(s) would the nurse consider? (Select all that apply.) A) Apply ice to the affected extremity B) Assess circulation every 2 hours C) Administer meperidine D) Massage the affected extremity E) Hold all narcotics F) Encourage oral fluid intake G) Monitor urinary output
B) Assess circulation every 2 hours D) Massage the affected extremity F) Encourage oral fluid intake G) Monitor urinary output Rationale: To monitor for ischemia, the nurse would routinely assess circulation during a vaso-occlusive crisis. Encouraging oral fluids and monitoring urine output prevent dehydration, which can cause further sickling. Massage, biofeedback, and aquatic therapy are all effective nonpharmacological pain control methods. Diligent pain control is an important element of sickle cell treatment, and narcotics may be administered as needed. The nurse could use heating pads, but ice packs would encourage further sickling and vaso-occlusion. Meperidine is contraindicated in pain treatment for sickle cell anemia because of the risk of a chemical reaction that may lead to a seizure.
Which assessment finding(s) for Brittany would the nurse document as within normal limits? (Select all that apply.) A) Pain of 10 on the FACES scale B) Blood pressure of 100/60 mmHg C) Temperature of 99°F (37.4°C) D) Respiratory rate of 26 breaths/min E) Heart rate of 102 beats/min F) Responsive when awakened
B) Blood pressure of 100/60 mmHg C) Temperature of 99°F (37.4°C) D) Respiratory rate of 26 breaths/min E) Heart rate of 102 beats/min F) Responsive when awakened Rationale: Normal blood pressure for a 5-year-old is 89-112/46-72 mmHg, so a blood pressure of 100/60 mmHg is within normal limits. A temperature of 99°F (37.4°C) would be normal. The normal heart rate for a 5-year-old is 80 to 120 beats/min, so a heart rate of 102 beats/min would be within normal limits. The normal respiratory rate for a preschooler is 20 to 28 breaths/min, so a respiratory rate of 26 breaths/min would also be within normal limits. A preschool child should be responsive and alert while awake. A pain rating of 10 would indicate severe pain and would not be within normal limits.
A 5-year-old patient with sickle cell anemia has an order for acetaminophen elixir 240 mg every 6 hours (15 mg/kg/dose) around the clock for pain. Which method is most appropriate for the nurse to employ to administer the medication? A) Use a dropper to place medication in the back of the patient's throat. B) Place medication in an oral syringe and allow the patient to squirt into their mouth. C) Put medication into a medicine cup and pour entire amount into patient's mouth at one time. D) Hide medication in applesauce or ice cream and have the caregiver feed the patient.
B) Place medication in an oral syringe and allow the patient to squirt into his or her mouth. Rationale: The preschool-aged or young school-aged child may enjoy using an oral syringe to squirt medication into their mouth; it is engaging and gives them a sense of control. A dropper is appropriate for use with infants and younger children; older children can take oral medication from a medicine cup or measured medicine spoon. Medication should be placed in the posterior side of the patient's cheek and should be given slowly in small amounts, allowing the patient to swallow before placing more medication into the mouth. To establish and maintain trust, it is important to tell children if there is medication mixed into food.
A patient with sickle cell disease experiencing a vaso-occlusive crisis comes to the emergency room for evaluation. Which of the following are acute manifestations of this disease that the nurse should expect to see in this patient? A) Anemia and hypotension B) Tachycardia and jaundice C) Acute leg pain and dactylitis D) Enuresis and proteinuria
C) Acute leg pain and dactylitis Rationale: Acute manifestations of sickle cell anemia in a vaso-occlusive crisis include pain crisis and swelling of the fingers and toes (dactylitis). Hypertension and tachycardia are often associated with acute pain. Anemia, jaundice, enuresis, and proteinuria are chronic manifestations of sickle cell anemia.
A nurse is caring for a pediatric patient who was recently diagnosed with sickle cell anemia. The patient's biological mother says, 'I don't understand how one of my children contracted this disease when the other doesn't have it.' In which way should the nurse respond? A) "Sickle cell anemia is transmitted through one biological parent. If you have four children, one—or 25%—will have sickle cell anemia." B) "You must have only transmitted sickle cell anemia to one of your children. Your other child definitely carries the trait." C) "Sickle cell anemia is not genetically transmitted." D) "Because both biological parents have the sickle cell trait, your risk for having a child with sickle cell anemia is 25% with each pregnancy."
D) "Because both biological parents have the sickle cell trait, your risk for having a child with sickle cell anemia is 25% with each pregnancy." Rationale: Sickle cell anemia is an autosomal recessive disorder; both parents must have the trait for a child to have the disease. With each pregnancy, there is a 25% chance the child will have sickle cell anemia, a 50% chance the child will be a carrier of the trait, and a 25% chance the child will be unaffected.
A nurse is explaining the pathophysiology of vaso-occlusive pain crisis to the caregiver of a patient with sickle cell anemia. Which explanation by the nurse is correct? A) "Bone marrow suppression occurs because of the development of sickled cells, which makes your child less able to fight infections." B) "Sickled cells cause increased blood flow throughout the body. The increased blood flow through the blood vessels causes your child to have severe pain." C) "Sickled cells mix with normal red blood cells and cause the immune system to become depressed, which makes your child more prone to illness." D) "Sickled cells clump together and cause the blood to become thicker, preventing blood flow through smaller vessels, causing decreased oxygenation and increased pain in the affected area."
D) "Sickled cells clump together and cause the blood to become thicker, preventing blood flow through smaller vessels, causing decreased oxygenation and increased pain in the affected area." Rationale: Sickle cell vaso-occlusive pain crisis occurs when sickled cells clump in the microvasculature, impeding blood flow (not increasing it); this causes local tissue hypoxia, which progresses to ischemia, resulting in severe pain as circulation to the affected area decreases. Bone marrow suppression and immune system depression are not involved in the pathophysiology of vaso-occlusive pain crisis
To prevent additional sickling and vaso-occulsion during a crisis, the nurse will _________ the objective of maintaining __________ .
apply oxygen percentage of sickle cells below 30% Rationale: The nurse would apply oxygen to prevent additional sickling and to increase oxygen supply for the tissues. During a vaso-occlusive crisis, providing intravenous hydration with an isotonic solution increases the hydrostatic pressure and volume and improves blood flow; a hypertonic solution will increase sickling and is contraindicated. Dialysis and transplantation are not used to treat vaso-occlusive crises. The nurse will keep the percentage of sickle cells in the circulatory flow below 30% and the hemoglobin volume greater than 10 g/dL to lower the risk of the child having a vaso-occlusive crisis. The platelet and red blood cell counts should be kept within normal limits; the normal red blood cell count for a 5-year-old child is 3.9 to 5.3 × 106/µL, and the normal platelet count for a 5-year-old child is 150,000 to 450,000/µL.
