A nurse is caring for a client who has sickle cell disease.
Client reports fatigue, muscle weakness, joint pain, and dyspnea. Sclera is jaundiced. A 2.5 cm (1 in) by 2.5 cm (1 in) open ulcer is noted on the inner left ankle.
For each client finding, click to specify if the finding is consistent with sickle cell disease, iron deficiency anemia, or leukemia. Each finding may support more than one disease process.
Joint pain
Heart Rate at 1000
Respiratory status
Jaundice
Ankle ulcer
The Correct Answer is {"A":{"answers":"A,C"},"B":{"answers":"A,B,C"},"C":{"answers":"A,B,C"},"D":{"answers":"A,C"},"E":{"answers":"A"}}
Joint Pain
Sickle Cell Disease: Joint pain is a common symptom of sickle cell disease due to vaso-occlusive crises, where sickle- shaped red blood cells block blood flow to the joints, causing pain and inflammation. These episodes can be severe and recurrent, leading to chronic pain and joint damage over time.
Leukemia: Joint pain can also be a symptom of leukemia, particularly in children. This occurs because leukemia cells can infiltrate the bone marrow, causing bone and joint pain. The pain is often due to the expansion of the marrow cavity by the leukemic cells.
Heart Rate at 1000
Sickle Cell Disease: An increased heart rate (tachycardia) can occur in sickle cell disease due to anemia. The body compensates for the reduced oxygen-carrying capacity of the blood by increasing the heart rate.
Iron Deficiency Anemia: Tachycardia is also a common symptom of iron deficiency anemia. The heart works harder to pump more blood to deliver adequate oxygen to tissues, resulting in an increased heart rate.
Leukemia: In leukemia, anemia can develop due to the replacement of normal bone marrow cells with leukemic cells, leading to a reduced number of red blood cells and subsequent tachycardia as the body attempts to compensate.
Respiratory Status
Sickle Cell Disease: Dyspnea (difficulty breathing) and labored breathing can occur in sickle cell disease due to anemia and acute chest syndrome, a severe complication where sickle cells block blood flow in the lungs.
Iron Deficiency Anemia: Respiratory symptoms such as shortness of breath and labored breathing are common in iron deficiency anemia due to the reduced oxygen-carrying capacity of the blood.
Leukemia: Leukemia can cause respiratory symptoms due to anemia and the infiltration of leukemic cells into the lungs, leading to reduced oxygenation and labored breathing.
Jaundice
Sickle Cell Disease: Jaundice is a common symptom of sickle cell disease due to the increased breakdown of red blood cells (hemolysis), leading to elevated bilirubin levels.
Leukemia: Jaundice can also occur in leukemia if the liver is infiltrated by leukemic cells or if there is significant hemolysis.
Ankle Ulcer
Sickle Cell Disease: Ankle ulcers are a common complication of sickle cell disease. They result from poor blood flow and oxygen delivery to the skin, leading to chronic, non-healing ulcers.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Hypothermia
Hypothermia, or abnormally low body temperature, is not a typical manifestation of acute osteomyelitis. Osteomyelitis usually presents with signs of infection, such as fever, rather than a drop in body temperature. Therefore, hypothermia is not a relevant symptom in this context.
Choice B reason: Localized edema
Localized edema, or swelling, is a common symptom of acute osteomyelitis. The infection in the bone can cause inflammation and swelling in the surrounding tissues. This is often accompanied by warmth and redness over the affected area. Therefore, localized edema is a key manifestation of acute osteomyelitis.
Choice C reason: Numbness of toes on the affected foot
Numbness of the toes is not a typical symptom of acute osteomyelitis. While nerve involvement can occur in severe cases, it is not a primary manifestation. Acute osteomyelitis primarily presents with signs of infection and inflammation, such as pain, swelling, and redness.
Choice D reason: Bradycardia
Bradycardia, or a slow heart rate, is not associated with acute osteomyelitis. The condition typically presents with systemic signs of infection, such as fever and malaise, rather than changes in heart rate. Bradycardia is more commonly related to cardiac conditions or certain medications.
Correct Answer is B
Explanation
Choice A reason: Administer a test dose first
Administering a test dose is not typically required for theophylline. Theophylline dosing is usually based on the patient’s weight and serum theophylline levels. A test dose is more commonly associated with medications that have a high risk of allergic reactions or require desensitization protocols, which is not the case with theophylline.
Choice B reason: Infuse the medication with an IV pump
Using an IV pump to infuse theophylline is essential to ensure accurate and controlled delivery of the medication. Theophylline has a narrow therapeutic range, and precise dosing is crucial to avoid toxicity. An IV pump allows for consistent infusion rates, reducing the risk of adverse effects. This is the most appropriate action for the nurse to take.
Choice C reason: Cover the IV container with dark paper
There is no need to cover the IV container with dark paper when administering theophylline. Theophylline is not light-sensitive, so this precaution is unnecessary. Covering IV containers is typically done for medications that degrade when exposed to light, such as certain antibiotics and chemotherapy agents.
Choice D reason: Infuse the medication at 35 mg/min
Infusing theophylline at a rate of 35 mg/min is excessively high and could lead to severe toxicity. The infusion rate for theophylline should be carefully calculated based on the patient’s weight and serum levels, and it is typically much lower than 35 mg/min. Rapid infusion can cause serious side effects, including arrhythmias and seizures.
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