A nurse is assessing a client who has sickle cell anemia. Which of the following findings is the priority for the nurse to report?
Slurred speech
Yellowed sclera
Ulcers on the ankles
Swelling in the joints
The Correct Answer is A
Choice A rationale:
Slurred speech could indicate a potential neurological complication in a client with sickle cell anemia, such as a stroke. Neurological symptoms require immediate attention and reporting to the healthcare provider.
Choice B rationale:
Yellowed sclera (jaundice) can be related to sickle cell anemia but is less acutely concerning than slurred speech.
Choice C rationale:
Ulcers on the ankles are often associated with sickle cell anemia, but they are not as urgent as neurological symptoms.
Choice D rationale:
Swelling in the joints is a potential manifestation of sickle cell anemia, but slurred speech indicates a more acute and concerning issue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Epinephrine auto-injectors should be stored at room temperature and protected from light. Refrigeration is not recommended.
Choice B rationale:
The solution in an epinephrine auto-injector should be clear. If it appears discolored or contains particles, it may be expired or compromised.
Choice C rationale:
Epinephrine auto-injectors should not be shaken before use, as shaking could cause the solution to foam and result in inaccurate dosing.
Choice D rationale:
Holding the epinephrine auto-injector in place for 10 seconds allows the medication to be fully delivered into the muscle, enhancing its effectiveness.
Correct Answer is D
Explanation
Choice A rationale:
This is not a priority intervention for a client who is in the manic phase of bipolar disorder. The nurse should monitor the client's vital signs as indicated, but blood pressure is not likely to be affected by mania unless the client has a preexisting condition or is taking medications that affect blood pressure.
Choice B rationale:
This is not an appropriate intervention for a client who is in the manic phase of bipolar disorder. The nurse should not restrict the client's physical activity, as this can increase their frustration and agitation. The nurse should provide a safe environment for the client to expend their energy and channel it into productive activities.
Choice C rationale:
This is not a suitable intervention for a client who is in the manic phase of bipolar disorder. The nurse should avoid stimulating the client's already elevated mood and arousal, as this can worsen their symptoms and increase their risk of injury or aggression. The nurse should limit the client's exposure to noise, crowds, and bright lights, and provide them with opportunities for rest and quiet time.
Choice D rationale:
A client who is in the manic phase of bipolar disorder has increased energy, activity, and metabolism, which can lead to weight loss and nutritional deficiencies. The nurse should provide the client with high-calorie finger foods that are easy to eat and do not require utensils or sitting down. This way, the nurse can help the client meet their nutritional needs while respecting their need for movement and autonomy.
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