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 B
Explanation
A. Radiation exposure: Radiation exposure can cause aplastic anemia, but if the cause is unknown, it is less likely to be due to a specific and identifiable event like radiation exposure.
B. An autoimmune disorder: When the cause of aplastic anemia cannot be diagnosed, it is often attributed to an autoimmune disorder where the body attacks its own bone marrow cells.
C. Chemotherapy drugs: Chemotherapy drugs can cause aplastic anemia, but this cause would typically be known based on the patient's medical history.
D. Toxins: Toxins can cause aplastic anemia, but like chemotherapy drugs and radiation, this cause would generally be identifiable.
Correct Answer is C
Explanation
A. Herpes simplex virus can cause genital herpes, but it typically does not lead to pelvic inflammatory disease. Pelvic inflammatory disease is more commonly associated with untreated chlamydia or gonorrhea infections.
B. Syphilis during pregnancy can lead to various complications such as stillbirth, neonatal death, or congenital syphilis in the newborn, but low birth weight is not a typical complication.
C. Human papillomavirus (HPV) infection is a known risk factor for the development of cervical cancer. Certain high-risk strains of HPV can lead to precancerous changes in cervical cells,
which, if left untreated, may progress to cervical cancer.
D. Meningitis is not a typical complication of chlamydia in males. In males, untreated chlamydia can lead to complications such as epididymitis or infertility.
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