A nurse is doing a physical examination of a child with sickle cell anemia. When the child asks why the nurse auscultates the lungs and heart, what would be the best response by the nurse?
To detect evidence of infection such as fever and tachycardia
To detect evidence of dehydration that might have triggered a sickle cell crisis
To detect abnormal sounds suggestive of acute respiratory complications and/or heart failure
To detect motor strength and stroke-related signs and symptoms
The Correct Answer is C
Reasoning:
Choice A reason: Detecting infection via fever and tachycardia is important in sickle cell anemia, but auscultation of lungs and heart is not primarily for these signs. Fever is assessed by temperature, and tachycardia by pulse, not stethoscope. Auscultation focuses on organ-specific complications like respiratory or cardiac issues, not systemic signs.
Choice B reason: Dehydration can trigger sickle cell crises, but auscultation of lungs and heart does not directly assess hydration status. Fluid status is evaluated through vital signs, skin turgor, or urine output, not heart or lung sounds, making this response less accurate for the purpose of auscultation.
Choice C reason: Auscultating lungs and heart in sickle cell anemia detects abnormal sounds indicating acute respiratory complications, like acute chest syndrome, or heart failure from chronic anemia or vaso-occlusion. Crackles, wheezes, or murmurs suggest these complications, making this the most accurate explanation for the child’s question.
Choice D reason: Motor strength and stroke-related signs are assessed through neurological exams, not lung or heart auscultation. While stroke is a risk in sickle cell anemia due to vaso-occlusion, auscultation targets cardiopulmonary complications, not motor or neurological deficits, making this response inappropriate.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is D
Explanation
Reasoning:
Choice A reason: A sodium level of 140 mEq/L is within the normal range and not diagnostic of Addison’s disease. This condition, caused by adrenal insufficiency, typically leads to hyponatremia due to reduced aldosterone, which decreases sodium reabsorption, making a normal sodium level uncharacteristic of the disease.
Choice B reason: A glucose level of 100 mg/dL is normal and not specific to Addison’s disease. Hypoglycemia is more common due to cortisol deficiency, which impairs gluconeogenesis. A normal glucose level does not support the diagnosis, as it does not reflect the metabolic disruptions of adrenal insufficiency.
Choice C reason: A blood pressure of 135/90 mm Hg is elevated but not diagnostic of Addison’s disease. The condition typically causes hypotension due to reduced aldosterone and cortisol, leading to low blood volume and vascular tone. Hypertension suggests another etiology, not adrenal insufficiency.
Choice D reason: A potassium level of 6.0 mEq/L indicates hyperkalemia, a diagnostic sign of Addison’s disease. Aldosterone deficiency reduces potassium excretion in the kidneys, leading to elevated serum potassium. This, combined with hyponatremia and hypotension, is a hallmark of adrenal insufficiency, making hyperkalemia a key diagnostic finding.
Correct Answer is D
Explanation
Reasoning:
Choice A reason: Decreased pain tolerance may occur in chronic conditions, but it is not the primary mechanism of pain in a sickle cell crisis. Pain results from vaso-occlusion by sickled red blood cells, causing tissue ischemia, not a psychological or tolerance issue, making this explanation incorrect.
Choice B reason: Overhydration does not enlarge red blood cells or cause sickle cell crises. Dehydration can trigger sickling by increasing blood viscosity, but overhydration dilutes plasma, potentially reducing sickling. Pain in crises stems from vaso-occlusion, not cell size changes due to fluid status.
Choice C reason: Bone marrow in sickle cell anemia increases, not decreases, erythrocyte production to compensate for chronic hemolysis. Hypoxia results from vaso-occlusion, not reduced production, as sickled cells block vessels, impairing oxygen delivery, making this an incorrect explanation for crisis-related pain.
Choice D reason: Vascular occlusion in small vessels by sickled red blood cells is the primary mechanism of sickle cell crisis pain. Sickled cells obstruct microvasculature, reducing blood flow and oxygen delivery, causing tissue ischemia and severe pain, accurately explaining the client’s symptoms in the emergency department.
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