A 7-year-old child with sickle cell anemia presents to the emergency department with severe pain in the arms and legs. What is the nurse's priority action?

Correct Answer: A

Rationale: In a sickle cell crisis, pain management is a priority due to the severe pain experienced by the child. Administering prescribed pain medication is crucial to alleviate the pain and provide comfort to the child. Once pain is controlled, other comfort measures like applying warm compresses and encouraging fluid intake can be implemented. Monitoring oxygen saturation is important but not the priority action when dealing with severe pain in a sickle cell crisis.

Correct Answer: A

Rationale: The priority action for the nurse is to ensure that a safety plan is in place before discharge. A safety plan is essential to assist the adolescent in managing future crises and decreasing the likelihood of another suicide attempt. It provides guidance on coping strategies and resources to help the adolescent stay safe in times of distress.

Correct Answer: C

Rationale: In assessing a child with suspected meningitis, photophobia (option C) is a characteristic sign of the condition. Photophobia is the sensitivity to light, which is common in individuals with meningitis due to the inflammation of the meninges surrounding the brain and spinal cord. This sensitivity occurs because light can exacerbate the headache associated with meningitis, leading to discomfort. Regarding the other options: A) A high-pitched cry can be a sign of distress or pain but is not a specific characteristic of meningitis. B) Tachycardia (fast heart rate) can occur in response to various stressors or infections, not solely indicative of meningitis. D) Hypotension (low blood pressure) is not a typical finding in meningitis unless severe complications have developed. In a pediatric nursing context, understanding the specific signs and symptoms of meningitis is crucial for early detection and prompt treatment to prevent serious complications. Educators should emphasize the importance of recognizing key indicators like photophobia to ensure timely intervention and optimal patient outcomes.

Correct Answer: B

Rationale: In the context of a child with suspected appendicitis, the assessment finding that should be reported to the healthcare provider immediately is sudden relief of pain (Option B). This is a critical sign as it may indicate a ruptured appendix, which is a medical emergency requiring immediate intervention. Sudden relief of pain can occur when the appendix perforates, leading to a temporary decrease in pain sensation due to the leakage of infectious material into the abdominal cavity. Nausea and vomiting (Option A) are common symptoms of appendicitis but are not as concerning as sudden relief of pain. Low-grade fever (Option C) is also a common symptom in appendicitis and may not be as urgent as sudden pain relief. Rebound tenderness (Option D) is a classic sign of appendicitis, but sudden pain relief takes precedence due to the potential complications associated with a ruptured appendix. Educationally, it is important for pediatric nurses to understand the significance of sudden pain relief in a child with suspected appendicitis to ensure prompt recognition and intervention in cases of appendiceal rupture. This knowledge can help prevent delays in treatment and improve patient outcomes.

Correct Answer: C

Rationale: Contact sports should be avoided in mononucleosis due to the risk of spleen rupture, which is a serious complication of the disease. The spleen can enlarge in mononucleosis, making it more susceptible to injury from contact sports, potentially leading to a life-threatening situation if rupture occurs.