A nurse is caring for a client with sickle cell disease. Which clinical finding indicates a vaso-occlusive crisis?
Severe joint and abdominal pain
Hypotension
Bleeding gums
Bradycardia
The Correct Answer is A
Rationale:
A. Severe joint and abdominal pain is the hallmark clinical manifestation of a vaso-occlusive crisis in clients with sickle cell disease. This occurs when sickled red blood cells obstruct small blood vessels, leading to ischemia and tissue hypoxia. The resulting tissue damage triggers intense pain, often described as acute, severe, and episodic. Pain can affect the joints, extremities, back, chest, and abdomen, depending on the location of vascular occlusion. Other accompanying findings may include fever, swelling, and tenderness in the affected areas. Vaso-occlusive crises are the most common reason for hospitalization in sickle cell patients and require prompt pain management and hydration to reduce sickling and improve blood flow.
B. Hypotension is not a typical finding during a vaso-occlusive crisis. Blood pressure may remain normal or be elevated due to pain and stress. Hypotension is more likely associated with severe anemia, hypovolemia, or septic complications rather than direct vaso-occlusion.
C. Bleeding gums suggest a bleeding or clotting disorder, such as thrombocytopenia or vitamin C deficiency, and are not characteristic of a vaso-occlusive crisis in sickle cell disease.
D. Bradycardia is not associated with vaso-occlusive crises. Heart rate may actually increase due to pain, stress, or anemia-related compensatory mechanisms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Frequent respiratory infections and salty skin is correct. Cystic fibrosis (CF) is a genetic disorder caused by mutations in the CFTR gene, which affects chloride and sodium transport across epithelial cells. This leads to thick, sticky mucus in the respiratory, gastrointestinal, and reproductive systems. In the lungs, the mucus traps bacteria, resulting in recurrent respiratory infections, chronic cough, and progressive lung damage. The defective chloride transport also causes excessive sodium in sweat, making the skin taste salty. These manifestations are hallmark signs of CF.
B. Bloody sputum and barrel chest is incorrect. While barrel chest can develop in chronic obstructive pulmonary diseases like emphysema, and bloody sputum may be present in advanced lung disease, these are not primary or early indicators of cystic fibrosis.
C. Painless open sores and petechiae are incorrect. These findings suggest hematologic or dermatologic disorders such as thrombocytopenia or vasculitis and are unrelated to cystic fibrosis.
D. Watery diarrhea and weight gain is incorrect. Cystic fibrosis commonly causes malabsorption and steatorrhea, leading to fatty, bulky stools and poor weight gain, rather than watery diarrhea and increased weight. Pancreatic enzyme insufficiency contributes to nutrient malabsorption.
Correct Answer is D
Explanation
Rationale:
A. Producing antibodies for immune response is incorrect. Antibody production is the function of B lymphocytes (a type of white blood cell), not erythrocytes. Red blood cells do not participate in the immune response.
B. Regulating body temperature is incorrect. While blood circulation helps distribute heat throughout the body, erythrocytes themselves do not directly regulate body temperature. Thermoregulation is a systemic process involving the hypothalamus, blood vessels, and sweat glands.
C. Forming blood clots to stop bleeding is incorrect. Blood clotting is primarily the role of platelets (thrombocytes) and clotting factors in plasma. Erythrocytes do not actively participate in coagulation.
D. Transporting oxygen from the lungs to the tissues is correct. Erythrocytes contain hemoglobin, a protein that binds oxygen in the lungs and carries it to tissues throughout the body. Hemoglobin also assists in transporting a portion of carbon dioxide from the tissues back to the lungs for exhalation. This oxygen delivery function is the primary responsibility of red blood cells and is critical for maintaining cellular metabolism and energy production.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.