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.

Answer and Explanation

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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Correct Answer is C

Explanation

A. Clotting is not directly related to the destruction of red blood cells.
B. Cyanosis refers to a bluish discoloration of the skin due to poor circulation or inadequate oxygenation, which is not directly indicative of red blood cell destruction.
C. Jaundice is the yellowing of the skin and eyes caused by the buildup of bilirubin, a byproduct of the destruction of red blood cells, which is a common symptom of hemolytic anemia.
D. Bleeding is not a symptom associated with the destruction of red blood cells but rather a lack of clotting factors or platelets.

A. An early sign is scrotal warmth and redness. B. Close male relatives are at increased risk for the disease. C. It typically occurs between ages 15 to 40. D. It occurs in both testicles equally. E. Impotence usually occurs after an orchiectomy.

Correct Answer is ["B","C"]

Explanation

A. Scrotal warmth and redness are not typically early signs of testicular cancer. Common signs include painless testicular swelling or a lump.
B. Close male relatives of individuals with testicular cancer have a higher risk of developing the disease themselves, suggesting a genetic component.
C. Testicular cancer typically occurs in younger men, with the highest incidence between ages 15 to 40.
D. Testicular cancer usually affects only one testicle, though it can occur in both.
E. Impotence is not a common complication of orchiectomy, the surgical removal of one or both testicles. However, other complications such as infertility may occur.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is admitted to determine why red blood cells are being quickly destructed in the body. What finding should the nurse associate with this patient's health problem?

Correct Answer is C

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