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 A
Explanation
A. Cystocele: A cystocele occurs when the bladder bulges into the vaginal canal, which can cause symptoms such as dyspareunia, backache, pelvic pressure, urinary tract infections, and urinary urgency.
B. Fibroid: Fibroids are benign tumors of the uterus and can cause pelvic pain and pressure, but they are not typically associated with urinary symptoms.
C. Ovarian cyst: Ovarian cysts can cause pelvic pain and pressure but are not usually associated with urinary symptoms like urinary urgency.
D. Rectocele: A rectocele occurs when the rectum bulges into the vaginal canal, which can cause symptoms like dyspareunia and pelvic pressure, but it is more likely to cause constipation than urinary urgency.
Correct Answer is A
Explanation
A. Inadequate production of platelets results in an increased risk of bleeding, making the client vulnerable to injury. Therefore, the priority nursing diagnosis is "Risk for Injury related to increased bleeding tendency."
B. Decreased antibody production is not directly related to inadequate platelet production.
C. While decreased platelet production may contribute to hypovolemia in some cases, the primary concern is the risk of bleeding rather than decreased cardiac output.
D. Impaired gas exchange is not directly related to inadequate platelet production.
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