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 A
Explanation
A. Alcohol can directly suppress the production of red blood cells (erythropoiesis) in the bone marrow, leading to anemia.
B. While alcoholics may indeed be deficient in folate due to poor nutrition, folate deficiency is not the primary mechanism for anemia in alcoholic liver disease.
C. Liver dysfunction can lead to decreased production of clotting factors, contributing to coagulopathy, but it is not the primary mechanism for anemia in alcoholic liver disease.
D. Gastric ulcers may indeed lead to chronic blood loss, contributing to anemia, but it is not specific to alcoholic liver disease.
E. While alcohol-induced inflammation may contribute to various complications, including liver damage, it is not the primary mechanism for anemia in alcoholic liver disease.
Correct Answer is B
Explanation
A. Decreased serum albumin is not typically associated with hemolysis; it may occur in conditions such as liver disease or malnutrition.
B. Jaundice, or yellowing of the skin and eyes, is a common manifestation of hemolysis due to the increased production of bilirubin from the breakdown of red blood cells.
C. Increased serum bilirubin levels occur as a result of hemolysis, contributing to the development of jaundice.
D. Increased bilirubin is essentially the same as increased serum bilirubin; both indicate the presence of jaundice due to hemolysis.
E. Presence of dark urine is also characteristic of hemolysis, as it may contain excess bilirubin, giving it a darker color.
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