When Mary's paternal grandmother, Earlene is informed that she has
a 7-year-old granddaughter, she immediately agrees to care for Mary. Earlene is a waitress and lives alone in a middle-class neighborhood in a small town about 85 miles from where Mary currently lives. Before placing Mary in a new home, COPS evaluates Earlene's physical, financial, and psychological ability to care for Mary. Earlene is not familiar with SCA. A nurse from CPS meets with her to discuss Mary's health condition. Earlene says to the nurse, "I have heard of sickle cell anemia, and I know it can be very bad, but I don't know exactly what it is."
1. What is the best response by the nurse to Earlene's statement?
-"I have some written material that will explain all about the disease."
-"It is a disease of the blood that requires taking medication every day."
-"Mary will probably have episodes of severe joint pain and will need to be hospitalized."
-Red blood cells become 'C' shaped, stiff, and sticky, which blocks the blood vessels.
2. How should the nurse respond?
-"As a Black woman, you must be aware that this is an inherited autosomal recessive disease.
-Mary has the disease because she inherited the gene from both of her parents, who were carriers.
-"It may be an awful disease but Mary can live a long productive life. "
-"She was exposed to a virus while her mother was pregnant."
While visiting with Earlene, the CPS nurse states, "Your son never told you he had a daughter? He was aware that he had a child. Mary's mother attempted to get child support before he left town. Do you know where he is and why he hasn't been a part of Mary's life? Earlene looks at the nurse and hesitates before responding?
3. Which statement by Mary's grandmother supports a common cultural communication expectation in the African-American heritage?
-"My son apparently wasn't ready to be a father."
-"Can't you have the police find him?"
-"Do you think Mary knows where her father is?"
-"I really don't want to talk about my son's situation."
The nurse is aware that the African American culture has expected family roles in the family organization. This information is critical when discussing Mary's entrance and acceptance into this already established family unit.
4. Which role does the grandmother usually play in the African American culture?
-In most African American families, the grandmother must be cased for by family.
-Many times, the grandmother is the brad winner, especially if there is no father.
-The grandmother usually plays a critical role in child care and economic support.
-The grandmother is usually the disciplinarian in the African American family.Caring Behaviors
After talking Earlene and assessing Mary's situation, the CPS nurse takes Mary to meet her grandmother's house. As the front door opens, Mary hides behind the nurse's back.
5. Which action will the CPS nurse take first?
-Ask the grandmother to wait in the house until she talks to Mary.
-Get down on the knees to calmly talk to Mary face-to-face.
-Explain that the nurse won't leave until Mary says it is all right.
-Hold Mary's hand and calmly walk into the house while talking to Mary.
After the nurse talks to Mary, the nurse and Mary walk into the grandmother's living room. Earlene and Mary just stare at each other without saying anything. Mary's grandmother gets tears in her eyes. Mary will not let go of the nurse's hand.
6. What should the nurse do?
-Take no action to allow Mary to make the first move.
-Sit down in the chair farthest away from Earlene.
-Encourage Mary to hold her grandmother's hand.
-Calmly introduce her paternal grandmother to Mary.
After a few minutes, Earlene opens up her arms, Mary goes into them, and they hug. The COPS nurse stays with them for a few hours until feeling assured that the child and grandmother are beginning to feel comfortable together. Both Earlene and Mary are talking and laughing as the nurse leaves the home.
Earlene takes Mary to the local elementary school, where Mary is enrolled in the second grade. She meets with the school nurse and discusses Mary's disease. The school nurse has cared for several children with SCA and is very knowledgeable about the disease and Mary's needs. The school nurse discusses Mary's condition with the classroom teacher.
7. Which intervention should the nurse implement?
-Explain that the other children should be really nice to Mary.
-Instruct the teacher to have Mary sit at the front of the classroom.
-Encourage Mary to participate in all playground activities.
-Request that Mary be allowed to go to the bathroom whenever she asks.
8. The school nurse reviews Mary's immunization records from her previous school. The nurse notes that Mary has had four scheduled does of DTaP, three scheduled doses of Hib, and one dose of MMR and received her Hep B series as an infant.
-Mary needs her second scheduled dose of MMR #2.
-Mary is current with her Hepatitis A immunizations
-Mary needs her influenza vaccine.A Complication Occurs
After attending school for 2 weeks without any problems, Mary reports to the school nurse that she doesn't feel well. The nurse determines Mary has a temperature of 102. The school nurse calls Earlene at the restaurant and advises her to take Mary directly to the ED. Mary complains of pain in her knees, in her elbows, and throughout her body. In the ED, the nurse confirms Mary's vital signs as T 102.4, P 104, R 24, BP 90/68, and pulse oximeter reading 91%.
9. Which action should the emergency department nurse implement first?
-Request arterial blood gases stat.
-Administer oxygen via nasal cannula.
-Send the grandmother to the admission office.
-Prepare to administer analgesics as prescribed.
10. The nurse notifies the emergency department physician of Mary's vital signs, which are: T 102.4, P 104, R 24, BP 90/68.
-Sickle-turbidity test (SIckledex)
The ED physician completes the assessment and diagnosis Mary with a vasoocculsive sickle cells crisis, probably secondary to pneumonia.
11. Which prescription should the nurse anticipate?
-Administer meperdine (Demerol) intravenously.
-Admit Mary to a private room and keep her in reverse isolation.
-Infuse 5% Dextrose in 0.33% NS at 75 mL/hr via pump.
-Insert a 22 French indwelling urinary catheter with an urimeter.
12. The emergency department nurse continually assesses Mary for signs and symptoms of hypoxia. Which area should the nurse assess to determine cyanosis in persons with dark skin?
-Palms of the hands.
-Sclera of the eyes.
13. Earlene is very upset and tells the nurse that she noticed that when Mary went to the bathroom to urinate there was blood in the commode. Which action should the nurse implement?
-Notify the healthcare provider immediately.
-Explain that blood in the urine is expected
-Assess Mary's perineal area for bleeding
-Request a stat sterile urine specimen
Mary is transferred from the emergency department to the pediatric intensive care department. In developing the plan of care, the nurse identifies the nursing diagnosis, "Acute pain related to tissue ischemia" as a priority.
14. Which intervention should be included in the care plan?
-Assess pain by using a numerical pain scale.
-Explain how to use a patient controlled analgesic pump.
-Apply cold compresses periodically to painful joints.
-Administer acetaminophen PRN for pain.
15. The night nurse assesses Mary and notes that her vital signs are now T 98.3, P 108, R 22, BP 96/60. Which action should the nurse implement?
-Notify the healthcare provider immediately.
-Retake and assess the vital signs in 1 hour.
-Encourage Mary to turn, cough, and deep breathe.
-Document the findings on the graphic sheet.
The ICU night nurse is making rounds and hears Mary crying. The nurse says, "Mary, are you hurting?" Mary cries harder and replies, "No, I just miss my Mommy." Mary's grandmother has gone home to rest for a few hours.
16. How should the nurse intervene initially?
-Say, "I know how hard it is to lose your Mommy. Mine is gone too."
-Tell Mary she needs to try and quit crying and get some sleep.
-Call Mary's grandmother and ask her to come to the hospital.
-Pull up a chair, hold Mary's hand, and allow her to cry.
Mary finally falls asleep. The night nurse allows her to sleep throughout the night without interruptions. The nurse gives Mary a hug, and offers what response?
-"Tell me why you think that your Mommy will never wake up from her sleep."
-"Mary, your Mommy did not go to sleep. Remember, she died in a car accident."
-"Your grandma will take good care of you and make sure you always wake up."
-"If you are very careful and do what you are told, you will not have to worry about that."Nursing Care on the Pediatric Unit
18. Mary is in the ICU for 3 days and is transferred to the pediatric floor. Earlene has been at the hospital every day and is very concerns about Mar and he condition. Earlene asks the nurse, "What can I do to make sure this never happens again?" What is the best initial response by the nurse?
-"When Mary gets a fever give her 1 baby aspirin."
-"Keep Mary away from anyone who has an infection."
-"There is no way you can make sure this never happens again."
-"Make sure she does not participate in any strenuous activity."
19. Mary's grandmother goes downstairs to get something to eat form the hospital cafeteria. The UAP who is staying with Mary while her grandmother is gone informs the primary nurse that Mary urinated in the bed, is crying, and wants her grandmother. Which intervention should the nurse implement first?
-Change Mary's bed linens.
-Help Mary change her clothes.
-Find Earlene in the cafeteria.
-Document the incident in Mary's chart.
The nurse calculates Mary's intake and output for the shift. Mary has had 24 ounces of water, 8 ounces of apple juice, and three 4-ounce cartons of milk. She received 50 mL of IV fluids per hour for the last 12 hours and had a urinary output of 1200 mL, plus one episode of wetting the bed.
-What is Mary's total intake for this shift? _____________mL
Growth & Development
Mary is starting to feel better and is requiring less pain medication, and she is sleeping as the nurse makes evening rounds. Earlene shares with the nurse it has been a long time since she has had a 7-year-old-in her home. Earlene says, "I have no idea what Mary should be allowed to do so she can have some fun."
21. Which statement will be the best response by the nurse?
-"You should like you are worried about raising Mary by yourself,"
-"I would recommend enrolling her in a sport with running, such as soccer.
-Seven-year-olds really like being in groups like Girl Scouts or Girl's Clubs.
-"Mary should not be around a lot of children, so her activities will be limited.
22. Which statement by Mary indicates that she is meeting Erickson's stage of development for her age?
-"Look, I finished putting the puzzle together."
-"I don't want any of my friends to visit me here."
-"I need my stuffed dog so that I can go to sleep."
-"When I grow up I want to be a nurse just like you."
Mary is scheduled for discharge the next day. The nurse is completing discharging teaching with Earlene when Earlene tells the nurse that she is planning to take Mary to Colorado to visit her oldest daughter and their family for the Christmas holidays. Mary is very excited and can't wait to meet her cousin.
23. What is the best response by the nurse?
-"I know that Mary will enjoy meeting her family."
-"I think you should talk to Mary's healthcare provider before you go."
-"Your planned trip may put Mary at risk for a crisis."
-"Could your daughter come here for the Christmas holidays?"
Earlene asks many questions about SCA. She is very concerned about her granddaughter and what will happen to her the future. The nurse is aware that there are many serious complications that Mary could experience.
24. Which potentially fatal complication(s) can occur? (Select all that apply.)
25. Mary's HCP has advised Earlene to get pneumococcal and meningococcal vaccines for Mary at her follow-up office visit. Earlene asks the nurse, "Why does Mary need to have those other vaccines? I hate for her to get more shots. She cries, and I know it hurts." What is the best response by the nurse?
-"I will get the healthcare provider to explain why Mary needs the vaccines."
-"She is susceptible to infections. These vaccinations may help prevent a crisis."
-"These vaccines are required for all children younger than 10 years of age."
-"I know you don't like to see her hurt, but she must have these vaccines."
The day shift is just coming on duty to the pediatric department where Mary is a client. The staff available includes two experience RNs, one new graduate who has just finished the 3-month pediatric internship, and two UAPs.
26. Which client should the charge nurse assign to the new graduate nurse?
-A 4-year-old child newly diagnosed with Cystic Fibrosis.
-Mary, who is scheduled as a probable discharge for tomorrow.
-A 9-year-old child who had an appendectomy 2 days ago.
-A 6-year-old child being evaluated for possible physical abuse.
The charge nurse is transcribing prescription at the nurse's station. Other responsibilities of the charge nurse include answering the phone assisting with visitor's questions and answering the clients' call lights.
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.
-Teach Mary's grandmother how to apply warm soaks to her joins.
-Clean the insertion sites of a client with skeletal traction.
-Change the morphine vial on the patient controlled analgesia pump.
Self Care at Home
Mary is discharged home with a home health referral. The home health nurse visiting Mary the day after she is discharged from the hospital. Earlene ask the home health nurse, "I received some information form the Sickle Cell Foundation, but I have never heard of it. What kind of group is it?"
28. How should the nurse respond?
-"It is a foundation that deals primarily with research to find the cure for sickle cell anemia."
-"It provides information on the disease and on support groups in this area."
-"They didn't discuss this organization with you when Mary was in the hospital?"
-"The foundation arranges for families with children who have sickle cell to meet each other."
29. To evaluate the discharge teaching completed at the hospital, the home health nurse discusses acute exacerbation of SCA with Mary's grandmother. Which behavior indicates to the nurse that Earlene understands about acute exacerbation of sickle cell anemia?
-She is able to take Mary's radial pulse within 4 beats of the nurse.
-She does not allow Mary to go outside unless she is with her.
-She measures Mary's fluid intake to remain under 1 liter a day.
-She demonstrates how to accurately read an oral thermometer.