A patient with a history of sickle cell disease is being admitted for sickle cell crisis. Which of the following nursing diagnoses should guide the nurse when providing care for the patient?
Risk for Injury related to compromised blood volume.
Risk for Deficient Fluid Volume related to infection.
Ineffective Airway Clearance related to sickled cells.
Ineffective Tissue Perfusion related to vascular occlusion.
The Correct Answer is D
A. Risk for Injury related to compromised blood volume is not the most appropriate nursing diagnosis for a patient with sickle cell disease in crisis. While patients may experience anemia and blood volume loss during a crisis, the primary concern is tissue perfusion due to vascular occlusion by sickled cells.
B. Risk for Deficient Fluid Volume related to infection is not directly related to the pathophysiology of sickle cell disease or sickle cell crisis.
C. Ineffective Airway Clearance related to sickled cells may be a concern for patients with sickle cell disease, especially during acute chest syndrome, but it is not the primary nursing diagnosis for a patient admitted for sickle cell crisis.
D. Ineffective Tissue Perfusion related to vascular occlusion is the most appropriate nursing diagnosis for a patient with sickle cell disease in crisis. Sickle cell crisis involves the occlusion of blood vessels by sickled cells, leading to impaired tissue perfusion and potential organ damage.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Performing breast self-examination (BSE) on the first day of each month provides a consistent schedule for the client to conduct the examination, making it easier to remember and ensuring regularity.
B. The first day of the menstrual cycle may not be the best time to perform BSE for all women, as breast tissue may be more tender or swollen during menstruation.
C. Seven days after the menstrual cycle begins may not be the best time for BSE, as hormonal fluctuations and breast changes may not yet have stabilized.
D. Performing BSE every month during ovulation is not necessary, as ovulation does not directly affect breast tissue changes that need to be monitored.
Correct Answer is A
Explanation
A. Monitor fluid intake and output. Monitoring fluid intake and output is essential in patients with multiple myeloma to assess for signs of dehydration or fluid overload, which can occur due to renal complications.
B. Limit weight bearing and ambulation. Limiting weight bearing and ambulation is not a
standard intervention for multiple myeloma unless there are specific complications such as bone fractures.
C. Assess lymph nodes for enlargement. Multiple myeloma primarily affects the bone marrow and plasma cells, not the lymph nodes.
D. Administer calcium supplements. While calcium supplementation may be necessary in some cases of multiple myeloma, it is not a priority action upon admission without further assessment.
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