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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Presence of plethora is a common symptom of polycythemia vera and indicates increased blood volume but is not immediately life-threatening.
B. Calf swelling and pain could indicate a deep vein thrombosis (DVT), which is a serious complication that requires immediate medical attention.
C. A platelet count of 450,000/microL is elevated but not as critical as the possibility of a DVT.
D. Hematocrit of 55% is high, which is expected in polycythemia vera, but it is not as immediately critical as the risk of thrombosis suggested by calf swelling and pain.
Correct Answer is B
Explanation
A. Hemophilia B results from a deficiency in clotting factor VIII. Hemophilia B results from a deficiency in clotting factor IX. Hemophilia A results from a deficiency in clotting factor VIII.
B. Males inherit hemophilia from their mothers. Hemophilia is an X-linked recessive disorder, meaning males inherit the defective gene from their carrier mothers.
C. Females inherit hemophilia from their fathers. Females can be carriers if they inherit the
defective gene from their mother, but they generally do not inherit the disease itself from their fathers due to the X-linked recessive inheritance pattern.
D. Hemophilia is a Y linked disorder. Hemophilia is not Y-linked; it is an X-linked recessive disorder.
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