The 8-year-old client diagnosed with a vaso-occlusive sickle cell crisis is complaining of a severe headache. Which intervention should the nurse implement first?1. Administer 6 L of oxygen via nasal cannula.2. Assess the client’s neurological status.3. Administer a narcotic analgesic by intravenous push (IVP). 4. Increase the client’s intravenous (IV) rate.
In this scenario, when an 8-year-old client diagnosed with a vaso-occlusive sickle cell crisis complains of a severe headache, the nurse should implement the intervention of assessing the client’s neurological status first
In this scenario, when an 8-year-old client diagnosed with a vaso-occlusive sickle cell crisis complains of a severe headache, the nurse should implement the intervention of assessing the client’s neurological status first.
Assessing the client’s neurological status is the priority because it helps the nurse determine the severity of the headache and identify any potential complications or changes in the client’s neurological functioning. This assessment will involve checking for symptoms such as changes in level of consciousness, motor abilities, speech, and sensory perception. The nurse should also assess for any other signs and symptoms that may indicate a worsening condition or complications, such as slurred speech, dizziness, or weakness on one side of the body.
By conducting a thorough neurological assessment, the nurse can gather vital information that will guide subsequent interventions and help determine the appropriate course of action. This assessment will form the basis for decision-making regarding the administration of oxygen, narcotic analgesics, or adjusting the intravenous (IV) rate.
While administering oxygen, providing pain relief with a narcotic analgesic, and adjusting the IV rate may be necessary interventions in managing a sickle cell crisis, it is essential to assess the client’s neurological status first to ensure that the most appropriate intervention is chosen. The focus should be on understanding the underlying cause of the severe headache and ruling out any neurological complications that may require immediate attention. Once the assessment has been completed and the severity of the headache and any potential neurological changes have been determined, the nurse can then implement the appropriate interventions based on the findings.
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