TJ, a 30-year-old client is admitted in sickle cell crisis with symptoms of dyspnea and leg pain. TJ's significant other asks, "I don't really understand why he is hurting so badly." Which of the following responses by the nurse is best?
"Clumping of abnormal red blood cells blocks the flow of blood through the capillaries."
"Bleeding in the joints occurs because red blood cells are being rapidly destroyed by the bone marrow."
"The pain is due to a disturbance in cellular metabolism."
"The bone marrow is expanding with the sickled cells and that causes pain."
The Correct Answer is A
A. This response accurately describes the pathophysiology of sickle cell crisis. During a crisis, sickled red blood cells clump together, leading to microvascular occlusion and impaired blood flow to tissues, resulting in pain.
B. Bleeding in the joints is not a characteristic feature of sickle cell crisis. It may occur in other conditions such as hemophilia or osteoarthritis but not in sickle cell crisis.
C. Disturbance in cellular metabolism is not the primary mechanism underlying the pain experienced during sickle cell crisis.
D. Bone marrow expansion with sickled cells may contribute to bone pain in sickle cell disease, but it is not the primary cause of pain during a sickle cell crisis.
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Related Questions
Correct Answer is B
Explanation
A. Hemophilia B results from a deficiency in clotting factor VIII. Hemophilia B results from a deficiency in clotting factor IX. Hemophilia A results from a deficiency in clotting factor VIII.
B. Males inherit hemophilia from their mothers. Hemophilia is an X-linked recessive disorder, meaning males inherit the defective gene from their carrier mothers.
C. Females inherit hemophilia from their fathers. Females can be carriers if they inherit the
defective gene from their mother, but they generally do not inherit the disease itself from their fathers due to the X-linked recessive inheritance pattern.
D. Hemophilia is a Y linked disorder. Hemophilia is not Y-linked; it is an X-linked recessive disorder.
Correct Answer is D
Explanation
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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