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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Inadequate production of platelets results in an increased risk of bleeding, making the client vulnerable to injury. Therefore, the priority nursing diagnosis is "Risk for Injury related to increased bleeding tendency."
B. Decreased antibody production is not directly related to inadequate platelet production.
C. While decreased platelet production may contribute to hypovolemia in some cases, the primary concern is the risk of bleeding rather than decreased cardiac output.
D. Impaired gas exchange is not directly related to inadequate platelet production.
Correct Answer is B
Explanation
A. Diarrhea: While diarrhea can occur in some cases of ovarian cancer, it is not one of the most common manifestations.
B. Unexplained weight loss: Unexplained weight loss is a common symptom of ovarian cancer and may be due to factors such as cancer-related cachexia or decreased appetite.
C. Urinary retention: Urinary retention is not a typical manifestation of ovarian cancer. Urinary symptoms may occur if the cancer spreads to nearby structures, but urinary retention is not
common.
D. Abdominal bloating: Abdominal bloating is a common symptom of ovarian cancer, often accompanied by feelings of fullness and increased abdominal girth. It is often one of the earliest and most noticeable symptoms of the disease.
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