How can the nurse determine that the outcomes of nursing interventions have been successful for the client diagnosed with a sickle cell crisis? (SELECT ALL THAT APPLY)

The client is free of chest pain and dyspnea.

The client describes the importance of increasing fluid intake.

The client increases aerobic exercises to promote endurance.

The client's acute pain is controlled at 3 on a standard pain scale.

Answer and Explanation

Correct Answer : A,B,D

Choice A reason:
Being free of chest pain and dyspnea is a significant indicator of successful nursing intervention in a sickle cell crisis. Chest pain and dyspnea can occur due to acute chest syndrome, a life-threatening complication of sickle cell disease characterized by vaso-occlusion in the pulmonary microcirculation. Effective pain management and oxygen therapy can alleviate these symptoms, reflecting improved respiratory function and gas exchange.

Choice B reason:
Educating the client on the importance of increasing fluid intake is crucial in managing sickle cell crisis. Adequate hydration helps to reduce blood viscosity and prevent sickling of red blood cells, which can lead to vaso-occlusive episodes. When a client verbalizes understanding and the importance of hydration, it demonstrates the effectiveness of patient education and the client's engagement in self-care.

Choice C reason:
While increasing aerobic exercises may promote endurance, it is not typically a short-term outcome measure for a sickle cell crisis. Exercise must be approached with caution in these clients, as it can increase the risk of a vaso-occlusive crisis due to dehydration and increased oxygen demand during a sickle cell crisis.

Choice D reason:
Control of acute pain to a level of 3 on a standard pain scale indicates successful pain management, a primary goal in the treatment of sickle cell crisis. Pain in sickle cell crisis is due to ischemia from obstructed blood flow by sickled cells. Effective analgesic administration and pain management strategies are essential to achieve this outcome.

Choice E reason:
A leukocyte count of 18,000/mm³ is above the normal range (4,500 to 11,000/mm³) and may indicate an infection or inflammation, which are common complications of sickle cell disease. However, this is not a direct outcome of nursing interventions aimed at managing a sickle cell crisis and thus is not a correct choice.

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Correct Answer is A

Explanation

Choice A Reason
Petechiae on the chest are a classic sign of fat emboli syndrome (FES). FES is a rare but serious complication that can occur after a long bone fracture, such as a femur fracture. The petechiae result from small fat droplets that travel to the skin's capillaries and cause pinpoint hemorrhages. This symptom is part of the classic triad for FES, which includes respiratory distress, neurological symptoms, and a petechial rash.

Choice B Reason
While an edematous calf may be a concern for deep vein thrombosis or other complications following a fracture, it is not a specific indicator of FES. Edema in the calf could be due to various reasons, including local trauma from the fracture itself or immobilization.

Choice C Reason
An elevated temperature can be associated with many post-injury complications, including infection or inflammatory response. However, it is not specific to FES. While patients with FES may present with fever, it is not one of the primary diagnostic criteria.

Choice D Reason
Paresthesia distal to the fracture could indicate nerve damage or compartment syndrome, which are important to assess in a patient with a femur fracture. However, paresthesia is not a specific sign of FES. The neurological symptoms associated with FES are more generalized and often include confusion or altered mental status.

A. Warms the hands with water prior to the procedure. B. Alternates fingers used in a systematic manner. C. Chooses the center of the finger pad as a puncture site. D. Verbalizes that a random result of 115 mg/dL indicates good glucose control.

Correct Answer is D

Explanation

Choice a reason:
Warming the hands with water before testing is actually a recommended practice. It helps increase blood flow to the fingertips, making it easier to get a sufficient blood sample for testing. Cold hands can restrict blood flow, leading to difficulty in obtaining a blood sample and potentially inaccurate results.

Choice b reason:
Alternating fingers for blood glucose testing is also a recommended practice. It helps prevent soreness and calluses on the fingers from repeated pricks. Using different fingers or different sides of the same finger can help reduce pain and potential damage to the skin.

Choice c reason:
Choosing the center of the finger pad as a puncture site is not recommended. The sides of the fingertips are preferred because they have fewer nerve endings, making the process less painful. The center of the finger pad has a denser nerve supply and can lead to more discomfort during the test.

Choice d reason:
A random blood glucose result of 115 mg/dL is slightly above the normal range for non-diabetics, which is typically between 70 to 99 mg/dL when fasting. For someone with diabetes, this result might be considered within a target range, depending on individual treatment goals set by healthcare providers. However, it's important to note that a single glucose reading does not provide a complete picture of glucose control. An A1C test, which reflects average blood glucose levels over the past 2-3 months, is also necessary to assess overall glucose management.

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How can the nurse determine that the outcomes of nursing interventions have been successful for the client diagnosed with a sickle cell crisis? (SELECT ALL THAT APPLY)

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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