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 A
Explanation
A. "Many herbal products have not undergone long-term testing for safety and efficacy.": This statement acknowledges the client's interest in herbal therapies while also providing important information about the potential risks associated with their use.
B. "Herbal therapies have no benefits and will not help your symptoms.": This statement is overly dismissive and may not be accurate, as some herbal therapies have been shown to provide symptom relief for menopausal symptoms.
C. "That is a good idea, as there are no ill effects associated with the use of herbal therapies.": This statement is inaccurate, as herbal therapies can have side effects and interactions with other medications.
D. "You should begin immediately, as they will help you.": This statement is not appropriate as it provides an unqualified endorsement of herbal therapies without considering potential risks or
individual circumstances.
Correct Answer is A
Explanation
A. The use of latex condoms. Latex condoms are highly effective in reducing the transmission of many STIs when used consistently and correctly.
B. Avoiding sexual contact if a partner is known to have an STI. While avoiding contact with an infected partner is important, many people may not know if their partner is infected, and this does not provide protection against unknown infections.
C. Vaccination against vaccine-preventable STIs. While vaccination is important (e.g., for HPV and hepatitis B), it does not protect against all STIs.
D. Limiting sexual partners. Limiting sexual partners can reduce risk but does not eliminate the risk of STIs if other protective measures are not used.
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