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","E"]
Explanation
A. The client's tongue being white is not typically associated with sickle cell crisis but may indicate other issues such as oral thrush.
B. Nausea can be a symptom associated with many conditions and is not specific to sickle cell crisis.
C. Jaundice is a common manifestation of sickle cell crisis due to hemolysis of red blood cells, leading to an increase in bilirubin levels.
D. Shortness of breath may occur in sickle cell crisis if there is severe anemia or if the crisis is complicated by acute chest syndrome, but it is not a defining characteristic.
E. Pain is a hallmark symptom of sickle cell crisis, occurring due to vaso-occlusion and tissue ischemia resulting from the sickling of red blood cells.
Correct Answer is A
Explanation
A. Raloxifene hydrochloride is a selective estrogen receptor modulator (SERM) that is used for the prevention and treatment of osteoporosis in postmenopausal women. It helps to prevent bone loss and reduce the risk of fractures by acting similarly to estrogen in some tissues and antagonizing estrogen in others.
B. Levothyroxine is a thyroid hormone replacement medication used to treat hypothyroidism, not osteoporosis.
C. Escitalopram oxalate is an antidepressant medication used to treat depression and anxiety disorders, not osteoporosis.
D. Calcitonin is a hormone involved in calcium regulation, and calcitonin nasal spray is sometimes used in the treatment of osteoporosis, but it is not typically the first-line treatment option.
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