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 D
Explanation
A. Skin color: While changes in skin color can occur in hemochromatosis due to excess iron deposition, it is not the most important parameter to monitor for the effectiveness of deferoxamine.
B. Liver function: Liver function tests can be abnormal in hemochromatosis due to iron overload, but monitoring liver function alone may not adequately assess the effectiveness of deferoxamine in reducing iron levels.
C. Hematocrit: Hematocrit measures the proportion of blood that is made up of red blood cells and may be elevated in hemochromatosis, but it is not the primary parameter to monitor the effectiveness of deferoxamine.
D. Serum iron level: Serum iron level is the most direct indicator of iron overload and the effectiveness of deferoxamine in chelating and removing excess iron from the body.
Correct Answer is A
Explanation
A. Hemophilia A: Hemophilia A is caused by a deficiency of factor VIII, leading to problems with blood clotting.
B. Hemophilia B: Hemophilia B is caused by a deficiency of factor IX, not factor VIII.
C. Christmas disease: Christmas disease is another name for Hemophilia B, which is caused by a deficiency of factor IX.
D. Sickle cell disease: Sickle cell disease is a genetic disorder affecting hemoglobin, not a clotting factor deficiency.
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