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?
The client's tongue is white.
The client is nauseated.
The client is jaundiced.
The client is short of breath.
The client reports feeling pain.
Correct Answer : C,E
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Decreased serum albumin is not typically associated with hemolysis; it may occur in conditions such as liver disease or malnutrition.
B. Jaundice, or yellowing of the skin and eyes, is a common manifestation of hemolysis due to the increased production of bilirubin from the breakdown of red blood cells.
C. Increased serum bilirubin levels occur as a result of hemolysis, contributing to the development of jaundice.
D. Increased bilirubin is essentially the same as increased serum bilirubin; both indicate the presence of jaundice due to hemolysis.
E. Presence of dark urine is also characteristic of hemolysis, as it may contain excess bilirubin, giving it a darker color.
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.
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