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 B
Explanation
A. Presence of plethora is a common symptom of polycythemia vera and indicates increased blood volume but is not immediately life-threatening.
B. Calf swelling and pain could indicate a deep vein thrombosis (DVT), which is a serious complication that requires immediate medical attention.
C. A platelet count of 450,000/microL is elevated but not as critical as the possibility of a DVT.
D. Hematocrit of 55% is high, which is expected in polycythemia vera, but it is not as immediately critical as the risk of thrombosis suggested by calf swelling and pain.
Correct Answer is ["C","E"]
Explanation
A. The client's tongue being white is not typically associated with sickle cell crisis but may indicate other issues such as oral thrush.
B. Nausea can be a symptom associated with many conditions and is not specific to sickle cell crisis.
C. Jaundice is a common manifestation of sickle cell crisis due to hemolysis of red blood cells, leading to an increase in bilirubin levels.
D. Shortness of breath may occur in sickle cell crisis if there is severe anemia or if the crisis is complicated by acute chest syndrome, but it is not a defining characteristic.
E. Pain is a hallmark symptom of sickle cell crisis, occurring due to vaso-occlusion and tissue ischemia resulting from the sickling of red blood cells.
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