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Answer Key Question 1 See full question 10s A preschool-age child with sickle cell anemia is admitted to the health care facility in vaso-occlusive crisis after developing a fever and joint pain. What is the nurse's highest priority when caring for this child? You Selected: • Administering antipyretics as ordered Correct response: • Providing fluids Explanation: During a vaso-occlusive crisis, sickle-shaped red blood cells (RBCs) clump together and obstruct blood vessels, causing ischemia and tissue damage. Therefore, the highest priority is providing I.V. and oral fluids, which promotes hemodilution and aids the free flow of RBCs through blood vessels. The client must be kept away from known infection sources but doesn't require protective isolation. Warm compresses may be applied to painful joints to promote comfort; cool compresses would cause vasoconstriction, which exacerbates sickling. Antipyretics may be administered to reduce fever but don't play a crucial role in resolving the crisis. Remediation: • Anemia, sickle cell, pediatric Question 2 See full question 24s A preschool-age child refuses to take ordered medication. Which nursing strategy is most appropriate? You Selected: • Showing trust in the child's ability to cooperate even with an unpleasant procedure Correct response: • Showing trust in the child's ability to cooperate even with an unpleasant procedure Explanation: To gain a preschooler's cooperation, the most appropriate strategy is for the nurse to show trust and express faith in the child's ability to cooperate even with an unpleasant procedure. Hiding the medication in milk may foster mistrust. The nurse should provide simple, not detailed, explanations and should use terms the child can understand. Shaming the child is inappropriate and may lead to feelings of guilt. Question 3 See full question 13s A boy, age 4, begins to use curse words. Concerned about this behavior, his parents ask the nurse how to discourage it. Which advice should the nurse offer? You Selected: • "Tell him it isn't acceptable and he'll be disciplined if he continues to do it." Correct response: • "Tell him it isn't acceptable and he'll be disciplined if he continues to do it." Explanation: The nurse should advise the parents to tell him it isn't acceptable because by explaining their objections and expectations, the parents teach the child why the behavior is unacceptable and help him understand that he must stop it. Telling the parents to ignore the behavior, or telling the child the behavior makes the parent angry, wouldn't teach the child that his behavior is inappropriate. Advising the parents to tell him good little boys don't use curse works would reinforce the impression that the child is "bad," diminishing his self-image while doing little to change the objectionable behavior. Question 4 See full question 19s When planning care for a child with epiglottiditis, the nurse should assign highest priority to which nursing diagnosis: You Selected:
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