The mother of a teenage boy with sickle cell anemia asks the nurse why her son has such horrible pain during a sickle cell crisis. Which of the following is the best response by the nurse?
"Dehydration Is the primary reason for the pain that is experienced during a sickle cell crisis; try to increase your son's fluid intake."
"We really don't know what causes the pain that is experienced during a sickle cell crisis."
"Sickled cells get clogged in the blood vessels, preventing blood from getting to the tissues, which causes the severe pain of a crisis."
"You will need to discuss this with your doctor. I cannot explain why this pain occurs to your son."
The Correct Answer is C
A. "Dehydration Is the primary reason for the pain that is experienced during a sickle cell crisis; try to increase your son's fluid intake."
This response is not the best choice because while dehydration can indeed exacerbate sickle cell crises and lead to complications, it is not the primary reason for the pain experienced during a sickle cell crisis. The severe pain during a crisis is primarily due to vaso-occlusion, where sickled red blood cells block blood flow in the small blood vessels, leading to tissue ischemia and pain. While adequate hydration is important in managing sickle cell disease, it alone does not address the underlying cause of the pain during a crisis.
B. "We really don't know what causes the pain that is experienced during a sickle cell crisis."
This response is not accurate and not the best choice because the medical community does understand the underlying cause of pain during a sickle cell crisis. It is primarily due to vaso-occlusion, as mentioned earlier, where sickled red blood cells block blood flow in the blood vessels.
C. "Sickled cells get clogged in the blood vessels, preventing blood from getting to the tissues, which causes the severe pain of a crisis."
This response is the best choice because it provides an accurate and clear explanation of why individuals with sickle cell anemia experience severe pain during a sickle cell crisis. It addresses the underlying mechanism of vaso-occlusion, where sickled red blood cells block blood flow in the small blood vessels, leading to tissue ischemia and severe pain.
D. "You will need to discuss this with your doctor. I cannot explain why this pain occurs to your
son."
This response is not the best choice because the nurse should be able to provide basic information about the disease and its symptoms to the mother. It's important for healthcare professionals to educate patients and their families about their condition to improve understanding and facilitate better management and coping strategies.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Hypertension is the leading cause of death in people your age.": While hypertension is a significant risk factor for cardiovascular events and mortality, stating it as the leading cause of death without specific context or statistical data may not provide the most informative response to the client's question.
B. "Hypertension puts you at increased risk of type 1 diabetes and cancer in your age group.": Hypertension is primarily associated with cardiovascular risks such as stroke, heart disease, and kidney disease. While it can contribute to overall health risks, it is not typically linked directly to type 1 diabetes or cancer in the context of this client's question.
C. "Hypertension can cause you to develop dangerous blood clots in your legs that can migrate to your lungs.": While hypertension can contribute to cardiovascular complications such as deep vein thrombosis (DVT) and pulmonary embolism (PE), these are not the primary risks that are typically emphasized when discussing the importance of treating hypertension.
D. "Hypertension greatly increases your risk of stroke and heart disease.": This response is the most relevant and specific to the client's question. Hypertension is a major risk factor for stroke, heart disease (including heart attack and heart failure), and other cardiovascular complications. By treating hypertension and controlling blood pressure within recommended targets, the client can significantly reduce the risk of these serious and potentially life-threatening conditions.
Correct Answer is A
Explanation
A. "Only take one nitroglycerin tablet for each episode of angina."
This instruction is correct. Sublingual nitroglycerin is typically administered as needed for the relief of angina symptoms, with one tablet being the initial dose. If the chest pain persists after 5 minutes, the client may take a second tablet, and if needed, a third tablet after another 5 minutes. However, if the pain is not relieved after three tablets, they should seek immediate medical attention.
B. "Place the nitroglycerin tablet between cheek and gum."
This instruction is incorrect. Sublingual nitroglycerin tablets should be placed under the tongue, allowing them to dissolve and be absorbed directly into the bloodstream. Placing the tablet between the cheek and gum is not the recommended administration route for sublingual nitroglycerin.
C. "Call 911 if you develop a headache following nitroglycerin use."
This instruction is partially correct. Headache is a common side effect of nitroglycerin due to its vasodilatory effects. Clients should be informed about this potential side effect, but not every headache following nitroglycerin use requires immediate medical attention. However, if the headache is severe, persistent, or accompanied by other concerning symptoms, the client should seek medical evaluation.
D. "See if rest relieves the chest pain before using the nitroglycerin."
This instruction is incorrect. Sublingual nitroglycerin is a rapid-acting medication used to relieve angina symptoms quickly. Clients should not delay taking nitroglycerin and wait for rest to relieve chest pain, as this can lead to worsening symptoms and complications.
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