A 12-year-old is diagnosed with a vaso-occlusive sickle cell crisis and complains of severe headaches. What should be the nurse’s initial action?
A 12-year-old is diagnosed with a vaso-occlusive sickle cell crisis and complains of severe headaches. What should be the nurse’s initial action?
A. Give oxygen at 6 liters per minute via nasal cannula.
[13%]
B. Assess the client’s neurologic status.
[51%]
C. Give an intravenous dose of morphine.
[19%]
D. Increase the client’s IV fluid rate.
[16%]
Statistics
Subject/Lesson
Subject
Child Health
Lesson
Hematological/Oncological
Client Need
Test Plan
Reduction of Risk Potential
Related Topic
Potential for Alterations in Body Systems
Item Type
Item Type
Application
Explanation
Choice B is correct. This client with sickle cell crisis has a high risk of cerebrovascular accidents (CVA). Since the client has a severe headache, it is best to rule out a CVA before initiating all other interventions.
Choice A is incorrect. Giving oxygen can help reduce the cells' sickling, but this is not the first intervention for the client’s headache. Furthermore, oxygen-carrying capacity is reduced when the cells are actively sickling. Increasing oxygen content in the blood will not significantly improve the oxygen-carrying capacity in a non-hypoxemic sickle cell client. There is no indication that the client is hypoxemic. (Note: If the information is absent in the question stem, that vital is considered normal. When evaluating the questions, do not add additional information to the question stems on the NCLEX).
Choice C is incorrect. The nurse must first assess to determine whether the pain is from what is expected with the disease process or whether it is a complication. Administering pain medications right away would mask the actual disease process.
Choice D is incorrect. Hydration can help in decreasing the sickling of cells. Choice D indicates that IV hydration is already in place. In SCD, the client should be kept euvolemic. Hypervolemia should be avoided because it can cause additional problems that come from fluid overload. Increasing the IV hydration without assessing the volume status is not the first intervention for this client.
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