A client with SCD presents to the healthcare facility with symptoms of fatigue, weakness, and dizziness.
The nurse is concerned about potential complications.
Which additional clinical manifestations should the nurse assess for?
"I've been having vision problems lately.”
"I've had delayed growth in my child.”
"I had a stroke a few years ago.”
"I'm experiencing chest pain, fever, and cough.”
The Correct Answer is D
Choice A rationale:
"I've been having vision problems lately." Rationale: Vision problems are not directly associated with complications of sickle cell disease (SCD)
SCD primarily affects the blood and vascular system, leading to symptoms such as anemia, pain crises, and organ damage.
Vision problems may be caused by other underlying conditions, but they are not a typical manifestation of SCD complications.
Choice B rationale:
"I've had delayed growth in my child." Rationale: Delayed growth in a child could be associated with SCD, as it may be a result of chronic anemia and inadequate oxygen delivery to tissues.
However, it is not a direct clinical manifestation of complications.
Other more common complications, such as pain crises, acute chest syndrome, or organ damage, should be assessed first to determine the extent of the disease's impact on the patient's health.
Choice C rationale:
"I had a stroke a few years ago." Rationale: This statement is significant because stroke is a known complication of sickle cell disease.
SCD can lead to the occlusion of blood vessels, including those in the brain, resulting in stroke.
Therefore, the nurse should assess for any neurological deficits and gather more information about the stroke episode to assess its severity and potential impact on the patient's current condition.
Choice D rationale:
"I'm experiencing chest pain, fever, and cough." Rationale: Chest pain, fever, and cough are indicative of acute chest syndrome (ACS), which is a severe complication of SCD.
ACS can lead to respiratory distress and is considered a medical emergency.
The presence of these symptoms warrants immediate assessment and intervention, making choice D the correct answer.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale:
Patients with sickle cell disease (SCD) have an increased risk of infection due to the compromised immune function associated with the disease.
SCD can lead to functional asplenia, making individuals more susceptible to infections, particularly those caused by encapsulated bacteria.
Choice B rationale:
Hypoxia (lack of oxygen) and ischemia (reduced blood flow) are common complications of SCD.
The sickle-shaped red blood cells can obstruct blood vessels, leading to reduced oxygen delivery to tissues (hypoxia) and tissue damage due to impaired blood flow (ischemia)
Choice C rationale:
Blood clot formation is a known complication of SCD.
The altered shape of sickle cells can lead to the blockage of blood vessels, causing painful vaso-occlusive crises and increasing the risk of clot formation.
Choice D rationale:
This choice is incorrect.
Reduced risk of stroke is not associated with SCD.
In fact, individuals with SCD may have an increased risk of stroke due to the potential for vasculopathy and clot formation.
Choice E rationale:
Reduced adhesion of red blood cells (RBCs) to the endothelium is not a typical feature of SCD.
In fact, the adhesion of sickle cells to the endothelium is one of the pathophysiological mechanisms leading to vaso-occlusive events in SCD.
Correct Answer is B
Explanation
Choice A rationale:
Oxygen therapy in the management of SCD is primarily aimed at preventing tissue hypoxia, not providing relief from severe pain.
SCD patients may experience pain due to tissue ischemia caused by the sickling of red blood cells, and oxygen can help prevent this by increasing the oxygen-carrying capacity of the blood.
Choice B rationale:
The primary purpose of oxygen therapy in the management of SCD is to prevent tissue hypoxia.
SCD patients are at risk of vaso-occlusive crises and tissue damage due to reduced oxygen delivery.
Supplemental oxygen helps maintain adequate tissue oxygenation and reduces the risk of complications.
Choice C rationale:
Oxygen therapy is not administered for the purpose of directly administering analgesics.
Analgesics are typically administered separately to manage pain in SCD patients.
Choice D rationale:
Oxygen therapy is not used to induce relaxation.
Its main goal is to improve oxygen saturation and prevent tissue hypoxia in SCD patients.
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