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?

Explain disease course and expected signs and symptoms to the family.

Check peripheral pulses, color, and temperature of extremities every 30 hours.

Reposition the client, paying close attention to proper body alignment.

Provide active range of motion (ROM) every 2 hours.

Answer and Explanation

The Correct Answer is C

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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Correct Answer is B

Explanation

A. Dusky mucous membranes are not typically associated with pernicious anemia.
B. A red tongue that is smooth and sore is a common finding in pernicious anemia due to vitamin B12 deficiency, which affects the epithelial cells of the tongue.
C. Shortness of breath on exertion can occur in many types of anemia but is not specific to pernicious anemia.
D. Dyspnea is also a common symptom in various anemias but is not as characteristic as the red, smooth, and sore tongue in pernicious anemia.

A. Schilling test B. Erythrocyte Indices C. Bone Marrow Biopsy D. Radiologic Studies

Correct Answer is A

Explanation

A. Schilling test. The symptoms described are suggestive of pernicious anemia, which is typically diagnosed through a Schilling test to assess vitamin B12 absorption.
B. Erythrocyte Indices. Erythrocyte indices are used to evaluate various aspects of red blood cell characteristics and are not specific to diagnosing pernicious anemia.
C. Bone Marrow Biopsy. While bone marrow biopsy may be used to diagnose certain types of anemia, it is not the primary diagnostic test for pernicious anemia.
D. Radiologic Studies. Radiologic studies are not typically used in the diagnosis of pernicious anemia.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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