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.

Exhibits

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

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A reason: Placing the shoulder harness straps below the level of the newborn’s armpits is incorrect. The shoulder harness straps should be at or below the level of the newborn’s shoulders to ensure a snug and secure fit.

Choice B reason: Keeping the car seat rear-facing until the newborn can sit unsupported is incorrect. The car seat should remain rear-facing until the child reaches the maximum height or weight limit specified by the car seat manufacturer, which is typically around 2 years of age.

Choice C reason: Placing the retainer clip across the newborn’s abdomen is incorrect. The retainer clip should be positioned at the level of the newborn’s armpits to ensure the harness straps are properly aligned and to prevent the baby from slipping out of the harness.

Choice D reason: Positioning the newborn at a 45-degree angle in the car seat is correct. This angle helps keep the newborn’s airway open and reduces the risk of airway obstruction. It also ensures that the baby is securely positioned in the seat.

A. Reinforce discharge teaching to clients. B. Instruct the assistive personnel (AP) to focus on clients’ ADLs. C. Stock additional unit supplies. D. Focus on providing care that prevents life-threatening emergencies.

Correct Answer is D

Explanation

Choice A reason: Reinforce discharge teaching to clients

While reinforcing discharge teaching is important, it is not the immediate priority during a disaster situation with limited staff. The focus should be on addressing urgent and life-threatening needs first. Discharge teaching can be addressed once the immediate crisis is managed and resources are more available.

Choice B reason: Instruct the assistive personnel (AP) to focus on clients’ ADLs

Instructing assistive personnel to focus on clients’ activities of daily living (ADLs) is important for maintaining basic care, but it is not the highest priority in a disaster situation. The primary focus should be on preventing life-threatening emergencies and ensuring the safety of all clients.

Choice C reason: Stock additional unit supplies

Stocking additional unit supplies is a proactive measure, but it is not the immediate priority during a disaster with limited staff. Ensuring that clients are safe and that life-threatening emergencies are prevented takes precedence over restocking supplies.

Choice D reason: Focus on providing care that prevents life-threatening emergencies

Focusing on providing care that prevents life-threatening emergencies is the highest priority in a disaster situation. With limited staff, it is crucial to prioritize interventions that ensure the immediate safety and well-being of clients. This includes monitoring for and addressing any critical changes in clients’ conditions and providing necessary emergency care.

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Heart Rate at 1000

Respiratory Status

Jaundice

Ankle Ulcer

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Explanation

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