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: Client reports knee pain changed from 4/10 to 6/10 is an important finding, but it is not as critical as a significant drop in blood pressure. Pain levels can fluctuate postoperatively, and while increased pain should be addressed, it does not typically require immediate notification of the provider unless it is severe or unmanageable.
Choice B reason: Pulse oximetry changed from 98% to 96% is a minor change and still within normal limits. A pulse oximetry reading of 96% is generally acceptable and does not indicate a critical issue that requires immediate provider notification.
Choice C reason: Temperature changed from 37.2°C (99.0°F) to 37.5°C (99.5°F) is a slight increase and still within the normal range. Postoperative patients can experience minor fluctuations in temperature, and this change does not typically indicate a serious problem.
Choice D reason: Systolic blood pressure changed from 140 mm Hg to 110 mm Hg is a significant drop and could indicate hypotension, which can be a serious complication, especially in an older adult post-surgery. Hypotension can result from various causes, including blood loss, dehydration, or effects of anesthesia, and requires prompt assessment and intervention.
Correct Answer is A
Explanation
Choice A reason: Using handrails in the bathroom is an effective fall prevention strategy. Handrails provide support and stability, especially in wet and slippery conditions, reducing the risk of falls. Bathrooms are common places for falls due to the presence of water and slippery surfaces. Installing handrails can significantly enhance safety for elderly residents.
Choice B reason: Getting a longer cord for the telephone is not a recommended fall prevention strategy. Long cords can create tripping hazards, especially if they are not properly managed. It is better to use cordless phones or ensure that cords are kept short and out of walkways to prevent falls.
Choice C reason: Placing a throw rug over electrical cords is not advisable. Throw rugs can slip and slide, creating a significant tripping hazard. Additionally, covering electrical cords with rugs can cause overheating and pose a fire risk. It is safer to secure cords along walls and use non-slip mats if necessary.
Choice D reason: Using chairs without armrests is not recommended for fall prevention. Armrests provide support when sitting down and standing up, helping to maintain balance and stability. Chairs with armrests can reduce the risk of falls by providing additional support for elderly residents.
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