A client with sickle cell anemia has "Pain related to thrombotic crisis" as a nursing diagnosis. Which of the following is the most appropriate nursing intervention for this diagnosis?
Explain disease course and expected signs and symptoms to the family.
Check peripheral pulses, color, and temperature of extremities every 30 hours.
Reposition the client, paying close attention to proper body alignment.
Provide active range of motion (ROM) every 2 hours.
The Correct Answer is C
A. Explain disease course and expected signs and symptoms to the family. While education is essential, it is not directly related to addressing the acute pain associated with thrombotic crisis.
B. Check peripheral pulses, color, and temperature of extremities every 30 hours. This intervention is important for assessing peripheral perfusion but may not directly address the acute pain associated with thrombotic crisis.
C. Reposition the client, paying close attention to proper body alignment. Repositioning the client to ensure proper body alignment can help alleviate pressure points and discomfort associated with thrombotic crisis.
D. Provide active range of motion (ROM) every 2 hours. While ROM exercises are important for preventing complications such as joint stiffness, they may not directly address the acute pain associated with thrombotic crisis.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "My doctor will perform pelvic exams to detect for ovarian cancer.": Pelvic exams can help detect ovarian cancer or abnormalities in the pelvic region, although they are not always definitive.
B. "I will develop ovarian cancer If I have the BRCA1 gene.": While having the BRCA1 gene mutation increases the risk of ovarian cancer, not everyone with this gene mutation will develop the disease.
C. "I will have regular Pap tests to monitor for ovarian cancer.": Pap tests are used to screen for cervical cancer, not ovarian cancer.
D. "A decreased CA125 level places me at greater risk for ovarian cancer.": An elevated CA125 level is associated with ovarian cancer, not a decreased level.
Correct Answer is A
Explanation
A. This response accurately describes the pathophysiology of sickle cell crisis. During a crisis, sickled red blood cells clump together, leading to microvascular occlusion and impaired blood flow to tissues, resulting in pain.
B. Bleeding in the joints is not a characteristic feature of sickle cell crisis. It may occur in other conditions such as hemophilia or osteoarthritis but not in sickle cell crisis.
C. Disturbance in cellular metabolism is not the primary mechanism underlying the pain experienced during sickle cell crisis.
D. Bone marrow expansion with sickled cells may contribute to bone pain in sickle cell disease, but it is not the primary cause of pain during a sickle cell crisis.
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