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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Related Questions
Correct Answer is C
Explanation
A. Menopause is the cessation of menstruation and marks the end of the reproductive years.
B. Menarche is the onset of menstruation and does not describe a phase of the menstrual cycle.
C. The follicular phase begins at the end of menses and ends at ovulation. During this phase, follicles in the ovaries mature, and one dominant follicle is selected for ovulation.
D. The luteal phase follows ovulation and ends with the start of menses. During this phase, the ruptured follicle transforms into the corpus luteum, which secretes progesterone to prepare the uterus for potential implantation of a fertilized egg.
Correct Answer is D
Explanation
A. Clay: Individuals with pica due to iron-deficiency anemia may crave and consume substances like clay.
B. Soil: Soil consumption is another manifestation of pica commonly seen in individuals with iron-deficiency anemia.
C. Ice: Some individuals with iron-deficiency anemia may crave and chew ice as a form of pica behavior.
D. Any of the responses: Pica is a condition where individuals have cravings for nonfood substances. In iron-deficiency anemia, pica can manifest as cravings for various nonfood items, including clay, soil, ice, and many others.
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