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 D
Explanation
Choice A reason:
Administering medication with an oral syringe is a recommended practice for giving liquid medication to infants. An oral syringe allows for accurate measurement and controlled delivery of the medication, reducing the risk of choking and ensuring the infant receives the correct dose. Therefore, this statement does not indicate a need for further instruction.
Choice B reason:
Inserting the medication in the infant’s buccal cavity (the space between the gums and the cheek) is also a recommended technique. This method helps to prevent the infant from spitting out the medication and ensures better absorption. Hence, this statement does not indicate a need for further instruction.
Choice C reason:
Allowing the infant to swallow some of the medication before administering more is a safe and effective way to give medication. This approach helps to prevent choking and ensures that the infant can handle the amount of medication being given. Therefore, this statement does not indicate a need for further instruction.
Choice D reason:
Positioning the infant in a supine position (lying flat on their back) is not recommended when administering oral medication. This position increases the risk of aspiration, where the medication could enter the airway instead of the esophagus. The correct position is to hold the infant in an upright or semi-upright position to ensure safe swallowing and reduce the risk of choking or aspiration. Therefore, this statement indicates a need for further instruction.
Correct Answer is C
Explanation
Choice A reason:
The purpose of a Jackson-Pratt (JP) drain is not to eliminate the need for wound irrigations. Wound irrigation is a critical step in wound care that helps remove debris, reduce bacterial load, and create an optimal environment for healing. The JP drain helps manage fluid accumulation but does not replace the need for proper wound irrigation.
Choice B reason:
While a JP drain can help manage bleeding by providing a pathway for blood to exit the wound, its primary purpose is not to limit bleeding. Instead, it is designed to prevent the accumulation of fluids such as blood, serous fluid, and other exudates that can impede healing and increase the risk of infection. Managing bleeding typically involves other interventions such as surgical hemostasis techniques.
Choice C reason:
The primary purpose of a Jackson-Pratt drain is to prevent fluid from accumulating in the wound. After surgery, wounds can produce various fluids, including blood and lymphatic fluid. Accumulation of these fluids can delay healing and increase the risk of infection. The JP drain uses gentle suction to draw these fluids away from the wound site, promoting faster healing and reducing the risk of complications.
Choice D reason:
A JP drain is not typically used to provide a means for medication administration. Medications are usually administered through other routes such as oral, intravenous, or through specialized catheters designed for medication delivery. The JP drain is specifically designed for fluid drainage and not for delivering medications.
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