which assessment findings should the nurse expect in a child with sickle cell anemia experiencing an acute vaso occlusive crisis
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Nursing Care of Children Final ATI

1. Which assessment findings should the nurse expect in a child with sickle cell anemia experiencing an acute vaso-occlusive crisis?

Correct answer: D

Rationale: The correct answer is D. Vaso-occlusive crises in sickle cell anemia are characterized by painful swelling of the joints in the hands and feet (hand-foot syndrome) and tissue engorgement due to the obstruction of blood flow by sickled cells. Choices A, B, and C are incorrect because circulatory collapse, hypovolemia, cardiomegaly, systolic murmur, hepatomegaly, and intrahepatic cholestasis are not typically associated with an acute vaso-occlusive crisis in sickle cell anemia.

2. The nurse manager is compiling a report for a hospital committee on the quality of nursing-sensitive indicators for a nursing unit. Which does the nurse manager include in the report?

Correct answer: C

Rationale: The education and certification of nurses are key nursing-sensitive indicators that reflect the quality of care provided on the unit.

3. When teaching a mother how to administer eye drops, where should the nurse tell her to place them?

Correct answer: C

Rationale: Eye drops should be placed in the conjunctival sac, which allows the medication to be absorbed properly without causing irritation. Placing drops directly on the sclera or near the lacrimal duct is less effective and can cause discomfort.

4. The nurse is interviewing the mother of an infant. The mother reports, "I had a difficult delivery, and my baby was born prematurely." This information should be recorded under which heading?

Correct answer: A

Rationale: The history section of the health record includes details about pregnancy, labor, and delivery, as these factors can have significant implications for the child's health.

5. The nurse is teaching parents about high-fiber foods that can prevent constipation. What foods should the nurse include in the teaching?

Correct answer: B

Rationale: The correct answer is B: All are correct. High-fiber foods like oranges, lima beans, baked beans, and raisin bran cereal are effective in preventing constipation. Oranges are a good source of fiber, lima beans and baked beans are high in fiber content, and raisin bran cereal is also rich in fiber. Bananas, which are not listed but could be considered by some as a high-fiber food, are actually low in fiber and may not be as effective in preventing constipation. Therefore, the nurse should include all the options provided in the teaching to help prevent constipation effectively.

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