A client diagnosed with sickle cell disease reports having pain in the chest and difficulty breathing.
The client states, "I have sharp chest pain, and it hurts more when I take a deep breath.”.
Which complication of sickle cell disease is the client likely experiencing?
Acute Chest Syndrome.
Renal Failure.
Cholelithiasis.
Functional Asplenia.
Monitor for signs and symptoms of anemia
Correct Answer : A,B,C,E
Choice D rationale:
Evaluation of psychosocial well-being and coping mechanisms Monitoring psychosocial well-being and coping mechanisms is essential for holistic care but may not directly relate to monitoring signs and symptoms of sickle cell disease.
The primary focus should be on physical assessments and symptoms related to the disease itself.
Now, let's provide rationales for The correct answers:
Choice A rationale:
Assessment of vital signs, including temperature, heart rate, blood pressure, and respiratory rate Monitoring vital signs is crucial for assessing a patient's overall health and detecting any signs of deterioration.
Patients with sickle cell disease can experience vaso-occlusive crises, which may result in changes in vital signs, such as an elevated heart rate and respiratory rate.
Elevated temperature may indicate an infection, which is another concern in sickle cell disease.
Choice B rationale:
Evaluation of pain intensity and location Sickle cell disease is associated with recurrent painful vaso-occlusive crises, where sickled red blood cells block blood vessels, leading to pain.
Assessing the intensity and location of pain is essential to determine the severity of the crisis and to provide appropriate pain management.
Choice C rationale:
Assessment of neurologic status, including cognitive function and sensory perception Sickle cell disease can lead to complications such as strokes, which may result in neurological deficits.
Monitoring cognitive function and sensory perception is crucial to detect any neurological complications early and provide timely interventions.
Choice E rationale:
Monitoring for signs and symptoms of anemia, such as fatigue, pallor, and shortness of breath Anemia is a common complication in sickle cell disease, and monitoring for signs and symptoms of anemia is vital.
Fatigue, pallor, and shortness of breath are typical manifestations of anemia, and early detection allows for appropriate management and intervention.
These assessments help in ensuring the comprehensive care of patients with sickle cell disease, addressing both acute and chronic complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
To increase the number of healthy red blood cells in the patient's body.
The primary goal of oxygen therapy in acute chest syndrome is not to increase the number of healthy red blood cells but to provide immediate relief by improving oxygenation.
Increasing healthy red blood cell production would take time and is not a suitable acute intervention.
Choice B rationale:
To reduce the frequency of pain crises and complications.
Oxygen therapy is not primarily aimed at reducing the frequency of pain crises.
It is used to address acute respiratory distress and improve oxygenation, which is essential in acute chest syndrome.
Choice D rationale:
To prevent infections and enhance the immune system response.
Oxygen therapy is not administered to prevent infections or enhance the immune system response.
Its main purpose is to address respiratory distress and hypoxia in patients with acute chest syndrome.
Correct Answer is D
Explanation
Jaundice and dark urine.
Choice A rationale:
Pale skin and nail beds are not typically the primary clinical manifestations of sickle cell disease during a crisis.
Sickle cell crises are primarily characterized by vaso-occlusive events leading to severe pain.
While paleness may occur due to anemia associated with sickle cell disease, it is not the hallmark manifestation during a crisis.
Choice B rationale:
An elevation in blood pressure is not a specific clinical manifestation of sickle cell disease.
In fact, individuals with sickle cell disease may experience a drop in blood pressure during a crisis due to reduced blood flow and organ perfusion.
Elevated blood pressure is more likely to be associated with other health conditions or stressors.
Choice C rationale:
Swelling of the lower extremities is not a typical clinical manifestation of sickle cell disease during a crisis.
The hallmark features of a sickling crisis include pain, jaundice, and, in some cases, dark urine, which results from the breakdown of sickled red blood cells.
Swelling may occur in other conditions but is not specific to sickle cell disease.
Choice D rationale:
Jaundice and dark urine are crucial clinical manifestations to monitor in a client with sickle cell disease during a crisis.
Jaundice indicates the breakdown of red blood cells, which is a common occurrence during vaso-occlusive events.
Dark urine results from the excretion of bilirubin, a byproduct of red blood cell breakdown.
These manifestations provide important diagnostic information and guide treatment.
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