A client with sickle cell disease (SCD) presents with jaundice and gallstones.
The client asks the nurse for an explanation.
Which response by the nurse is correct?

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.

Choice A rationale:

Monitoring for signs of transfusion reaction is a critical nursing responsibility during and after a blood transfusion.

Transfusion reactions, such as fever, chills, rash, or dyspnea, can occur due to various factors, including compatibility issues or bacterial contamination of the blood product.

Detecting these signs promptly allows for immediate intervention, including stopping the transfusion and providing appropriate treatment.

This ensures the patient's safety and well-being during the transfusion process.

Choice B rationale:

Monitoring the patient's response to music therapy is not a standard nursing assessment during or after a blood transfusion.

While music therapy can have benefits in managing pain and anxiety, it is not directly related to the safety of the transfusion process.

Choice C rationale:

Monitoring the patient's fluid intake and output is essential in many clinical situations, but it is not specifically related to the safety of a blood transfusion.

This parameter is more relevant in assessing the patient's hydration status and renal function.

Choice D rationale:

Monitoring the patient's emotional state is important for overall patient care, but it is not a primary concern during and immediately after a blood transfusion.

The focus during this time should be on detecting any adverse reactions or complications related to the transfusion itself.