The practical nurse (PN) reviews the history of an older adult who is newly admitted to a long term care facility.

Which factor in the resident's history should the PN consider the most likely to increase the client's risk for falls?

Correct Answer: B. Joint pain.

Choice B rationale:

Joint pain is the most common symptom experienced by individuals during a sickle cell crisis. The misshapen red blood cells can block blood flow to joints, leading to severe pain and inflammation. Joint pain is a hallmark sign of a sickle cell crisis, and managing pain is a critical aspect of caring for these patients.

Choice A rationale:

Decreased hemoglobin is not the expected symptom during a sickle cell crisis. A sickle cell crisis is characterized by sudden and severe pain due to the misshapen red blood cells blocking blood flow and causing tissue damage. While a sickle cell crisis can lead to anemia, the child experiencing the crisis would be more likely to describe pain and not specifically mention decreased hemoglobin.

Choice C rationale:

Infection is not a typical symptom experienced during a sickle cell crisis. While sickle cell disease can increase the risk of infections, the crisis itself primarily manifests as acute pain due to vaso-occlusion.

Choice D rationale:

Fatigue may be experienced by individuals with sickle cell disease, especially during or after a crisis, but it is not the most likely symptom they would describe during a sickle cell crisis. The hallmark symptom of a sickle cell crisis is severe pain.

The correct answer is choice C. Suction the oral and nasal passages.

Choice A rationale:

Turning the infant onto the right side may not be the most appropriate intervention for cyanosis caused by regurgitation. Cyanosis signifies a lack of oxygen, and simply changing the infant's position might not address the underlying issue.

Choice B rationale:

Giving oxygen by positive pressure is not the immediate intervention needed for regurgitation-induced cyanosis. While administering oxygen is important, the first step should involve clearing the airway to ensure proper oxygenation.

Choice C rationale:

Suctioning the oral and nasal passages is crucial in this situation as the cyanosis is likely due to the infant's airway being obstructed by regurgitated material. Clearing the airway can restore normal breathing and oxygenation.

Choice D rationale:

Stimulating the infant to cry is not the appropriate action when cyanosis is present. Cyanosis indicates a serious problem with oxygenation, and crying may worsen the situation by further compromising the infant's breathing.