A nurse is admitting a client who has sickle cell anemia. Which of the following manifestations should the nurse expect with this condition?(Select All that Apply.)

Pain

Anxiety

Sleeplessness

Difficulty speaking

Depression

Answer and Explanation

Correct Answer : A,B,C,E

A.   Pain is one of the hallmark symptoms of sickle cell anemia, particularly during a sickle cell crisis. The sickling of red blood cells can obstruct blood flow, leading to ischemia and severe pain in various parts of the body, including the chest, abdomen, and joints.
B.   Clients with sickle cell anemia often experience anxiety, especially during pain crises or hospitalizations. The uncertainty surrounding pain episodes, potential complications, and the chronic nature of the disease can contribute to feelings of anxiety.
C.   Many individuals with sickle cell anemia may experience sleeplessness due to pain, discomfort, or anxiety related to their condition. Pain episodes can disrupt sleep patterns, leading to fatigue and further complicating their overall health.
D.   Difficulty speaking is not a typical manifestation of sickle cell anemia. While severe complications, such as stroke, can occur in individuals with sickle cell disease and may lead to speech difficulties, this is not a direct manifestation of the condition itself.
E.   Depression is common among individuals with chronic illnesses, including sickle cell anemia. The ongoing challenges of managing pain, frequent medical visits, and the impact of the disease on daily life can contribute to feelings of depression.

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Correct Answer is ["A","B","D"]

Explanation

A. This task is appropriate for UAP to perform, as it involves basic hygiene and does not require nursing judgment or clinical assessment. UAP can assist with routine oral care under the direction of the RN.
B. Assisting with position changes is a basic care activity that UAP can perform. This task helps prevent pressure ulcers and maintains client comfort, and it does not require the clinical judgment of a nurse.
C. Administering IV medications or fluids is a nursing task that requires specific training and knowledge of nursing assessments, potential complications, and monitoring. This task should only be performed by a licensed nurse, not by UAP.
D. UAP can document basic measurements such as urine output, as this is a straightforward task that does not require clinical judgment. However, the RN should ensure that the UAP understands how to accurately measure and record this information.
E. While UAP can observe and report general changes, monitoring for clinical indications of dehydration requires nursing assessment skills and judgment. This task should be performed by an RN.
F. While UAP can weigh clients, the assessment of weight trends requires clinical judgment and interpretation of data, which falls under the responsibilities of a licensed nurse. The RN should evaluate and interpret the data regarding the client's health status.

A. Accompany a client who has depression to occupational therapy. B. Initiate soft wrist restraints on a client who is at risk for self-harm. C. Sit with a client who has alcohol use disorder and whose last drink was five days ago. D. Set limits with a client who has mania. E. Work a jigsaw puzzle with a client who has dementia. F. Assess a client who has hypomania for exhaustion.

Correct Answer is ["A","E"]

Explanation

A. This is a routine task that can be safely delegated to a NAP. It does not require complex decision- making or assessment skills.
B. This task requires the ability to assess the client's condition and determine the appropriate level of restraint. It is a task that should be performed by an RN or licensed practical nurse (LPN).
C. While this may seem like a simple task, it requires the ability to monitor the client for signs of withdrawal and to intervene if necessary. It is a task that should be performed by an RN or LPN.
D. This task requires the ability to assess the client's behavior and to intervene if necessary. It is a task that should be performed by an RN or LPN.
E. This is a therapeutic activity that can be delegated to a NAP. It can help to stimulate the client's cognitive function and provide social interaction.
F. This task requires the ability to assess the client's condition and identify potential complications. It is a task that should be performed by an RN or LPN.

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A nurse is admitting a client who has sickle cell anemia. Which of the following manifestations should the nurse expect with this condition?(Select All that Apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","B","D"]

Explanation

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Correct Answer is ["A","E"]

Explanation

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