a school age child is admitted to the pediatric unit with a vaso occlusive crisis which of these should be included in the nursing plan of care

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ATI Nursing Care of Children

1. A school-age child is admitted to the pediatric unit with a vaso-occlusive crisis. Which of these should be included in the nursing plan of care?

A. Correction of alkalosis
B. Pain management and administration of heparin
C. Adequate oxygenation and replacement of factor VIII to correct the sickling
D. Adequate hydration, oxygenation, and pain management

Correct answer: D

Rationale: The correct answer is D. Vaso-occlusive crises in sickle cell anemia require a comprehensive approach that includes adequate hydration to reduce blood viscosity, oxygenation to prevent further sickling of red blood cells, and aggressive pain management. This approach helps improve tissue perfusion and manage pain effectively. Choices A, B, and C are incorrect. Correction of alkalosis is not a priority in vaso-occlusive crisis management. Administration of heparin is not indicated as it can increase the risk of bleeding in sickle cell patients. Factor VIII replacement is not relevant to sickle cell anemia as it is a treatment for hemophilia, not sickle cell disease.

2. What interventions should be implemented to maintain the skin integrity of a preterm infant born at 30 weeks?

A. Avoid cleaning the skin
B. Bathe the infant with sterile water
C. Cleanse the skin with a gentle alkaline-based soap and water
D. Thoroughly rinse the skin with plain water after bathing

Correct answer: B

Rationale: The correct intervention to maintain the skin integrity of a preterm infant born at 30 weeks is to bathe the infant with sterile water. Bathing with sterile water or a neutral pH solution is recommended to protect the delicate skin of preterm infants, which is more permeable and prone to damage. Choices A, C, and D are incorrect as avoiding cleaning the skin may lead to hygiene issues, cleansing with alkaline-based soap can be harsh on the delicate skin, and thoroughly rinsing with plain water after bathing may not be as gentle and protective for preterm infants.

3. Which explains the importance of detecting strabismus in young children?

A. Color vision deficit may result.
B. Amblyopia, a type of blindness, may result.
C. Epicanthal folds may develop in the affected eye
D. Corneal light reflexes may fall symmetrically within each pupil

Correct answer: B

Rationale: Undetected strabismus can lead to amblyopia, where the brain favors one eye over the other, potentially resulting in permanent vision loss in the affected eye.

4. Where in the health history does a record of immunizations belong?

A. History
B. Present illness
C. Review of systems
D. Physical assessment

Correct answer: A

Rationale: Immunizations are part of the patient’s health history and are recorded under the history section to ensure the child is up-to-date with vaccinations.

5. What is the recommended method to assess hydration status in infants?

A. Capillary refill time
B. Skin turgor
C. Urine output
D. Mucous membranes

Correct answer: C

Rationale: The correct answer is C: Urine output. Assessing urine output is a recommended method to determine hydration status in infants. Adequate urine output indicates good hydration, while decreased urine output may suggest dehydration. Capillary refill time (Choice A) is more indicative of circulatory status rather than hydration. Skin turgor (Choice B) is a useful assessment in adults but can be less reliable in infants. Checking mucous membranes (Choice D) can provide some information on hydration, but it is not as reliable as assessing urine output in infants.