A 16-year-old is admitted with sickle cell crisis. The patient has a pain scale rating of 10 and the following vital signs: HR 115, BP 120/82, RR 18, oxygen saturation 91%, temperature 101.4°F. Select all the appropriate nursing interventions for this patient at this time?

Remove restrictive clothing or objects from the patient

Administer IV Morphine per MD order

Administer oxygen per MD order

Place on NPO

Start intravenous fluids per MD order

Keep patient on bed rest

Answer and Explanation

Correct Answer : A,B,C,D,E,F

A.   Remove restrictive clothing or objects from the patient: This helps to promote comfort and improve circulation.
B.   Administer IV Morphine per MD order: Morphine is a common medication used to manage severe pain associated with sickle cell crisis.
C.   Administer oxygen per MD order: Oxygen may be needed to improve oxygen saturation and support respiratory function, especially if the patient is hypoxic.
D.   Place on NPO: This is appropriate in case the patient needs any procedures or interventions that require fasting.
E.   Start intravenous fluids per MD order: Intravenous fluids help to hydrate the patient and improve blood flow, which can help alleviate symptoms of sickle cell crisis.
F. Keep patient on bed rest: Bed rest is important to conserve energy and minimize the risk of further complications during a sickle cell crisis.

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Correct Answer is C

Explanation

A. Explain disease course and expected signs and symptoms to the family. While education is essential, it is not directly related to addressing the acute pain associated with thrombotic crisis.
B. Check peripheral pulses, color, and temperature of extremities every 30 hours. This intervention is important for assessing peripheral perfusion but may not directly address the acute pain associated with thrombotic crisis.
C. Reposition the client, paying close attention to proper body alignment. Repositioning the client to ensure proper body alignment can help alleviate pressure points and discomfort associated with thrombotic crisis.

D. Provide active range of motion (ROM) every 2 hours. While ROM exercises are important for preventing complications such as joint stiffness, they may not directly address the acute pain associated with thrombotic crisis.

A. The client's tongue is white. B. The client is nauseated. C. The client is jaundiced. D. The client is short of breath. E. The client reports feeling pain.

Correct Answer is ["C","E"]

Explanation

A. The client's tongue being white is not typically associated with sickle cell crisis but may indicate other issues such as oral thrush.
B. Nausea can be a symptom associated with many conditions and is not specific to sickle cell crisis.
C. Jaundice is a common manifestation of sickle cell crisis due to hemolysis of red blood cells, leading to an increase in bilirubin levels.
D. Shortness of breath may occur in sickle cell crisis if there is severe anemia or if the crisis is complicated by acute chest syndrome, but it is not a defining characteristic.
E. Pain is a hallmark symptom of sickle cell crisis, occurring due to vaso-occlusion and tissue ischemia resulting from the sickling of red blood cells.

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A 16-year-old is admitted with sickle cell crisis. The patient has a pain scale rating of 10 and the following vital signs: HR 115, BP 120/82, RR 18, oxygen saturation 91%, temperature 101.4°F. Select all the appropriate nursing interventions for this patient at this time?

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Naxlex Comprehensive Predictor Exams

A client with sickle cell anemia has "Pain related to thrombotic crisis" as a nursing diagnosis. Which of the following is the most appropriate nursing intervention for this diagnosis?

Correct Answer is C

Explanation

A 30-year-old who is experiencing sickle cell crisis is admitted to the hospital. During the admission assessment, which findings can the nurse attribute to the client's blood disorder?

Correct Answer is ["C","E"]

Explanation

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