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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Related Questions
Correct Answer is A
Explanation
A. The activity of the bone marrow is depressed. Aplastic anemia is a condition where the bone marrow fails to produce sufficient numbers of blood cells, including red cells, white cells, and platelets.
B. Red cells are absent as a result of chronic blood loss. This describes a condition like iron- deficiency anemia, not aplastic anemia.
C. The bone marrow fails to produce lymphocytes. Aplastic anemia affects the production of all blood cells, not just lymphocytes.
D. The kidneys fail to produce red blood cells. This describes anemia of chronic kidney disease, not aplastic anemia. In aplastic anemia, the problem lies with the bone marrow, not the kidneys.
Correct Answer is B
Explanation
A. Phalitis: This term is not commonly used and does not specifically refer to swelling in the hands and feet.
B. Dactylitis: Dactylitis is a common manifestation of sickle cell disease in infants, characterized by painful swelling of the hands and feet due to vaso-occlusive episodes.
C. Erythromelaglia: Erythromelalgia is a condition characterized by burning pain, redness, and warmth in the extremities, but it is not typically associated with sickle cell disease.
D. Dyshidrotia: This term is not commonly used in medical terminology and does not specifically refer to swelling in the hands and feet.
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