A nurse is caring for a client who has sickle cell disease.

Exhibits

For each client finding, click to specify if the finding is consistent with sickle cell disease, iron deficiency anemia. or leukemia. Each finding may support more than 1 disease process.

Jaundice

Respiratory status

Ankle ulcer

Joint pain

Heart rate at 1000

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A,C"},"C":{"answers":"A"},"D":{"answers":"A,C"},"E":{"answers":"A,B,C"}}

Rationale Assessment Findings Jaundice

Sickle Cell Disease: Yes. Jaundice occurs due to hemolysis of red blood cells, which is common in sickle cell disease as the sickled cells break down more rapidly than normal red blood cells.

Iron Deficiency Anemia: No. Jaundice is not a characteristic finding of iron deficiency anemia. Leukemia: No. Jaundice is not typically associated with leukemia.

Respiratory Status

Sickle Cell Disease: Yes. Clients may experience dyspnea and labored breathing due to vaso-occlusive crises, which can lead to lung involvement (acute chest syndrome).

Iron Deficiency Anemia: No. While severe anemia can lead to fatigue and shortness of breath, it does not typically cause labored breathing as a primary finding.

Leukemia: Yes. Respiratory issues can arise if leukemia causes significant bone marrow infiltration or if there is an infection due to immunosuppression.

Ankle Ulcer

Sickle Cell Disease: Yes. Chronic ulcers are common in sickle cell disease due to poor circulation and vaso-occlusive episodes.

Iron Deficiency Anemia: No. Ankle ulcers are not a characteristic finding in iron deficiency anemia. Leukemia: No. While leukemia can lead to skin issues or infections, ulcers are not a typical finding. Joint Pain

Sickle Cell Disease: Yes. Joint pain is a common symptom due to vaso-occlusive crises, where sickled cells block blood flow to the joints.

Iron Deficiency Anemia: No. Joint pain is not a common symptom of iron deficiency anemia.

Leukemia: Yes. Joint pain can occur due to leukemic infiltration of the bone marrow or as a side effect of treatments.

Heart Rate at 1000 (112/min)

Sickle Cell Disease: Yes. Tachycardia can occur in response to pain, hypoxia, or anemia due to sickle cell disease.

Iron Deficiency Anemia: Yes. Increased heart rate can occur as the body compensates for decreased hemoglobin and oxygen-carrying capacity.

Leukemia: Yes. Tachycardia can also be seen in leukemia, particularly if the patient is anemic or experiencing systemic effects of the disease.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. This option focuses on involving the client in their own care and goal-setting. By establishing attainable goals together, the nurse can help the client regain a sense of control and motivation, which may encourage participation in therapy.
B. This option uses a form of coercion, implying that the client must comply with therapy to earn privileges. While consequences for non-participation can be a component of care, this approach may increase resistance and feelings of resentment.
C. This approach is punitive and likely to worsen the client's emotional state. Limiting support from family and friends can increase feelings of isolation and abandonment, potentially leading to greater resistance to therapy.
D. While offering the client some control can be beneficial, this option may lead to inconsistencies in therapy participation. If the client chooses to minimize their participation or avoid therapy altogether, it could hinder their rehabilitation progress. However, a balanced approach that includes some client choice alongside structured therapy may be beneficial.

A. Check the value of the client's current platelet count. B. Instruct the client to use an electric toothbrush. C. Have the client make an appointment to see the dentist. D. Explain to the client that this is an expected adverse effect.

Correct Answer is A

Explanation

A. Methotrexate can cause myelosuppression, leading to low platelet counts (thrombocytopenia), which increases the risk of bleeding. Checking the platelet count will help assess whether the bleeding gums are related to low platelet levels and determine the need for further intervention.
B. An electric toothbrush can be gentler on the gums and may help reduce trauma to the oral mucosa, which can help minimize bleeding. However, while it is a good practice, it is not the immediate priority compared to checking the platelet count.
C. This action may be appropriate, especially if the bleeding persists or is severe. A dental evaluation is important to rule out any underlying dental issues that could be causing the bleeding gums. However, this should not be the first response without first assessing the cause of the bleeding, such as checking the platelet count.
D. While some degree of bleeding may occur due to thrombocytopenia associated with methotrexate, it
is not appropriate to dismiss the client’s symptoms as merely an expected effect. Bleeding gums can indicate a serious issue, and it’s important to take such complaints seriously and investigate the underlying cause.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client who has sickle cell disease. Exhibits For each client finding, click to specify if the finding is consistent with sickle cell disease, iron deficiency anemia. or leukemia. Each finding may support more than 1 disease process.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A rehabilitation nurse is caring for a client who has had a spinal cord injury that resulted in paraplegia. After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitative efforts by the staff. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse in a provider's clinic is assessing a client who has cancer and a prescription for methotrexate PO. Which of the following actions should the nurse take when the client reports bleeding gums?

Correct Answer is A

Explanation

A nurse is assessing a client who has a spinal cord injury. Which of the following assessment findings should the nurse expect with neurogenic shock? (Select all that apply.)

A rehabilitation nurse is caring for a client who has had a spinal cord injury that resulted in paraplegia. After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitative efforts by the staff. Which of the following actions should the nurse take?

A nurse is teaching a client who has a spinal cord injury about sexual stimulation. Which of the following statements by the nurse should be included in the teaching?

A nurse is reviewing the laboratory results of a client who has acute leukemia and received an aggressive chemotherapy treatment 10 days ago. Which of the following hematologic laboratory values should the nurse expect? (Select all that apply.)

A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should the nurse expect? (Select all that apply.)

A nurse is caring for a client who has a spinal cord injury at the fourth cervical level. Which of the following mobility options should the nurse anticipate for this client?

A home health nurse is caring for a client who is quadriplegic following a spinal cord injury and who is adjusting to the home environment. Which of the following client statements indicate the client is adapting?

A nurse is caring for a 17-year-old client who is experiencing a relapse of leukemia and is refusing treatment. The client's mother insists that the client receive treatment. Which of the following actions should the nurse take?

A nurse is caring for a client who has sickle cell disease.

Exhibits

For each client finding, click to specify if the finding is consistent with sickle cell disease, iron deficiency anemia. or leukemia. Each finding may support more than 1 disease process.