A 30-year-old who is experiencing sickle cell crisis is admitted to the hospital. During the admission assessment, which findings can the nurse attribute to the client's blood disorder?
The client's tongue is white.
The client is nauseated.
The client is jaundiced.
The client is short of breath.
The client reports feeling pain.
Correct Answer : C,E
A. The client's tongue being white is not typically associated with sickle cell crisis but may indicate other issues such as oral thrush.
B. Nausea can be a symptom associated with many conditions and is not specific to sickle cell crisis.
C. Jaundice is a common manifestation of sickle cell crisis due to hemolysis of red blood cells, leading to an increase in bilirubin levels.
D. Shortness of breath may occur in sickle cell crisis if there is severe anemia or if the crisis is complicated by acute chest syndrome, but it is not a defining characteristic.
E. Pain is a hallmark symptom of sickle cell crisis, occurring due to vaso-occlusion and tissue ischemia resulting from the sickling of red blood cells.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Reticulocyte count: Reticulocyte count measures immature red blood cells and is not the primary measure for the effectiveness of filgrastim, which is used to boost white blood cells.
B. White blood count / Absolute neutrophil count: Filgrastim (Neupogen) is used to increase white blood cells, specifically neutrophils. Therefore, monitoring the white blood count (WBC) and absolute neutrophil count (ANC) is the appropriate way to determine the effectiveness of the drug.
C. Total lymphocyte count: While lymphocytes are a type of white blood cell, filgrastim primarily affects neutrophils, making WBC/ANC a better indicator.
D. Platelet count: Filgrastim does not directly impact platelet production, so platelet count is not the primary measure of its effectiveness.
Correct Answer is ["A","B","C","D","E","F"]
Explanation
A. Remove restrictive clothing or objects from the patient: This helps to promote comfort and improve circulation.
B. Administer IV Morphine per MD order: Morphine is a common medication used to manage severe pain associated with sickle cell crisis.
C. Administer oxygen per MD order: Oxygen may be needed to improve oxygen saturation and support respiratory function, especially if the patient is hypoxic.
D. Place on NPO: This is appropriate in case the patient needs any procedures or interventions that require fasting.
E. Start intravenous fluids per MD order: Intravenous fluids help to hydrate the patient and improve blood flow, which can help alleviate symptoms of sickle cell crisis.
F. Keep patient on bed rest: Bed rest is important to conserve energy and minimize the risk of further complications during a sickle cell crisis.
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