HESI Case Studies–Pediatrics-Sickle Cell Anemia (Mary) – Flashcards
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5. Which action will the CPS nurse take first?
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Get down on the knees to calmly talk to Mary face-to-face
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6. What should the nurse do?
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Calmly introduce her paternal grandmother to Mary
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7. Which intervention should the nurse implement/
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Request that Mary be allowed to go to the bathroom whenever she asks
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8. Which recommendation about immunization should the school nurse make to Mary's grandmother?
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Mary needs her second scheduled dose of MMR #2
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9. What action should the emergency department nurse implement first?
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Administer oxygen via nasal cannula
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10. The nurse anticipates the prescription of which diagnostic test by the emergency department physician?
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Blood cultures
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11. Which prescription should the nurse anticipate?
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Infuse 5% Dextrose in 0/33% NS at 75mL/hr via pump
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12. Which area should the nurse assess to determine cyanosis in persons with dark skin?
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Oral mucosa
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13. Which action should the nurse implement?
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Explain that blood in the urine is expected
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14. Which intervention should be included in the care plan?
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Explain how to use a patient controlled analgesic pump
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15. Which action should the nurse implement?
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Document the findings on the graphic sheet
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16. How should the nurse intervene initially?
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Pull up a chair, hold Mary's hand, and allow her to cry
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17. The nurse gives Mary a hug, and offers what response?
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"Mary, your mommy did not go to sleep. Remember, she died in a car accident."
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18. What is the best initial response by the nurse?
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"There is no way you can make sure this never happens again."
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19. Which intervention should the nurse implement first?
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Help Mary change her clothes
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20. What is Mary's total intake for this shift?
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1920
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21. Which statement will be the best response by the nurse?
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"Seven-year-olds really like being in groups like Girl Scouts or Girls' Clubs."
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22. Which statement by Mary indicates that she is meeting Erikson's stage of development for her age?
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"Look, I finished putting the puzzle together."
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23. What is the best response by the nurse?
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"Your planned trip may put Mary at risk for a crisis."
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24. Which potentially fatal complications can occur (Select all)
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-Cerebral vascular accident -Heart failure
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25. What is the best response by the nurse?
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"She is susceptible to infection. These vaccinations may help prevent a crisis."
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26. Which client should the charge nurse assign to the new graduate nurse?
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A 9-year-old child who had an appendectomy 2 days ago
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27. Which nursing task would be best for the charge nurse to delegate to the UAP?
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Take the hourly vital signs for a client receiving a unit of blood
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28. How should the nurse respond?
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"It provides information on the disease and on support groups in this area."
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29. Which behavior indicates to the nurse that Earlene understands about acute exacerbations of sickle cell anemia?
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She demonstrates how to accurately read an oral thermometer
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