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 ["A","C","D","E"]
Explanation
Choice A rationale:
Agitation is a common manifestation of delirium, as the client experiences a disturbance in attention, awareness, and cognition. The client may become restless, irritable, or aggressive due to the altered mental state.
Choice B rationale:
Slow, flat speech is not a manifestation of delirium, but rather a sign of depression or dementia. Clients with delirium may have rapid, incoherent, or slurred speech, depending on the cause and severity of the condition.
Choice C rationale:
Visual hallucinations are another manifestation of delirium, as the client may perceive things that are not there or misinterpret sensory stimuli. The client may also have auditory or tactile hallucinations, which can contribute to the agitation and confusion.
Choice D rationale:
Confusion is a hallmark manifestation of delirium, as the client has difficulty with orientation, memory, and reasoning. The client may not recognize familiar people or places, or may have fluctuating levels of consciousness. The confusion may worsen at night or in low-light settings, which is known as sundowning syndrome.
Choice E rationale:
Rapid mood swings are also a manifestation of delirium, as the client may exhibit emotional lability, anxiety, depression, fear, or anger. The mood changes may be unpredictable and inappropriate to the situation.
Correct Answer is C
Explanation
Choice A rationale:
Drainage in the Hemovac is an expected finding postoperatively and is not as urgent as nonreactive pupils.
Choice B rationale:
Periorbital ecchymosis (bruising around the eyes) is not uncommon after a craniotomy and is not as urgent as nonreactive pupils.
Choice C rationale:
Nonreactive pupils can indicate a neurological emergency, such as increased intracranial pressure or potential damage to the cranial nerves. This finding requires immediate attention to prevent further complications.
Choice D rationale:
Hemoglobin level of 11 g/dL is within a normal range and is not a priority concern.
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