HESI Case Studies–Pediatrics-Sickle Cell Anemia (Mary)

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