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 D
Explanation
A. "Conscious sedation will be administered to you prior to the procedure." Needle aspiration breast biopsies typically use local anesthesia, not conscious sedation.
B. "The results of the biopsy will be immediately available." Biopsy results usually take a few days to be processed and reviewed.
C. "You may place a heating pad on the breast to relieve discomfort following the procedure." Applying a cold pack, rather than a heating pad, is generally recommended to reduce swelling and bruising.
D. "You should wear a well-fitting bra to minimize bruising following the procedure." Wearing a well-fitting bra can provide support and help minimize bruising and discomfort after the
procedure.
Correct Answer is B
Explanation
A. Reticulocyte count: Reticulocyte count measures immature red blood cells and is not the primary measure for the effectiveness of filgrastim, which is used to boost white blood cells.
B. White blood count / Absolute neutrophil count: Filgrastim (Neupogen) is used to increase white blood cells, specifically neutrophils. Therefore, monitoring the white blood count (WBC) and absolute neutrophil count (ANC) is the appropriate way to determine the effectiveness of the drug.
C. Total lymphocyte count: While lymphocytes are a type of white blood cell, filgrastim primarily affects neutrophils, making WBC/ANC a better indicator.
D. Platelet count: Filgrastim does not directly impact platelet production, so platelet count is not the primary measure of its effectiveness.
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