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 C
Explanation
A. Menopause is the cessation of menstruation and marks the end of the reproductive years.
B. Menarche is the onset of menstruation and does not describe a phase of the menstrual cycle.
C. The follicular phase begins at the end of menses and ends at ovulation. During this phase, follicles in the ovaries mature, and one dominant follicle is selected for ovulation.
D. The luteal phase follows ovulation and ends with the start of menses. During this phase, the ruptured follicle transforms into the corpus luteum, which secretes progesterone to prepare the uterus for potential implantation of a fertilized egg.
Correct Answer is D
Explanation
A. Clay: Individuals with pica due to iron-deficiency anemia may crave and consume substances like clay.
B. Soil: Soil consumption is another manifestation of pica commonly seen in individuals with iron-deficiency anemia.
C. Ice: Some individuals with iron-deficiency anemia may crave and chew ice as a form of pica behavior.
D. Any of the responses: Pica is a condition where individuals have cravings for nonfood substances. In iron-deficiency anemia, pica can manifest as cravings for various nonfood items, including clay, soil, ice, and many others.
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