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 C
Explanation
A. DIC is not characterized by decreased production of clotting factors. Instead, it involves consumption of clotting factors due to widespread activation of coagulation.
B. While platelet dysfunction may occur in DIC due to consumption and depletion of platelets, the primary pathophysiological process in DIC is the activation of clotting factors and formation of blood clots throughout the vasculature.
C. Excessive activation of clotting factors and widespread clot formation is the primary pathophysiological process in DIC. This leads to the formation of numerous small blood clots throughout the body's blood vessels, resulting in organ dysfunction and potentially life-threatening complications.
D. Excessive platelet production is not a characteristic feature of DIC. Instead, platelets are consumed and depleted as they are incorporated into the blood clots formed during the
coagulation cascade in DIC.
Correct Answer is D
Explanation
A. Syphilis can indeed affect many areas of the body, including the brain and heart, but this statement does not specifically address primary syphilis, which is characterized by the appearance of a painless sore (chancre) at the site of infection.
B. Syphilis does not typically resolve on its own. Without treatment, the infection can progress to more severe stages with potentially serious complications.
C. Syphilis is caused by a bacterial infection (Treponema pallidum) and is treated with antibiotics such as penicillin. Antiviral medications are not effective against bacterial infections like syphilis.
D. This statement is accurate and important for the prevention of syphilis transmission. Syphilis can be transmitted through vaginal, anal, or oral sex, but the risk of transmission is lower during oral sex compared to vaginal or anal intercourse.
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