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 is aware that if patients from different cultures are implied to be inferior, the emotional attitude the nurse is displaying is what?

Correct answer: B

Rationale: Ethnocentrism is the belief that one's own culture is superior to others, which can lead to bias and a lack of cultural competence in healthcare.

3. An infant requires surgery for repair of a cleft lip. An important priority of the preoperative nursing care is which?

Correct answer: B

Rationale: Performing a baseline physical and behavioral assessment is crucial to determine the infant's current health status and to identify any potential risks before surgery.

4. The mother of a 6-year-old boy who has recently had surgery for the removal of his tonsils and adenoids complains that he has begun sucking his thumb again. Which defense mechanism should the nurse include when responding to the mother?

Correct answer: B

Rationale: The correct answer is B: Regression. Regression is a common defense mechanism where a child reverts to an earlier stage of development, such as thumb-sucking, to cope with stress. In this scenario, the 6-year-old boy is using thumb-sucking (a behavior typical of earlier developmental stages) as a way to deal with the stress of surgery. Repression (choice A) involves unconsciously blocking out thoughts or feelings, which is not applicable in this case. Rationalization (choice C) is a defense mechanism where illogical or unreasonable explanations are provided to justify behavior, which is not relevant here. Fantasy (choice D) refers to the use of imagination to escape from reality, which is also not the appropriate defense mechanism for the situation described.

5. What is the best indicator of fluid balance in a pediatric patient?

Correct answer: C

Rationale: Weight is the most accurate indicator of fluid balance in pediatric patients. Changes in weight reflect shifts in body fluid levels more directly compared to other parameters. Blood pressure and heart rate may be affected by various factors other than fluid balance. While urine output is important in assessing renal function, it may not provide a comprehensive picture of overall fluid balance in pediatric patients.

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