A patient with a history of sickle cell disease is being admitted for sickle cell crisis. Which of the following nursing diagnoses should guide the nurse when providing care for the patient?
Risk for Injury related to compromised blood volume.
Risk for Deficient Fluid Volume related to infection.
Ineffective Airway Clearance related to sickled cells.
Ineffective Tissue Perfusion related to vascular occlusion.
The Correct Answer is D
A. Risk for Injury related to compromised blood volume is not the most appropriate nursing diagnosis for a patient with sickle cell disease in crisis. While patients may experience anemia and blood volume loss during a crisis, the primary concern is tissue perfusion due to vascular occlusion by sickled cells.
B. Risk for Deficient Fluid Volume related to infection is not directly related to the pathophysiology of sickle cell disease or sickle cell crisis.
C. Ineffective Airway Clearance related to sickled cells may be a concern for patients with sickle cell disease, especially during acute chest syndrome, but it is not the primary nursing diagnosis for a patient admitted for sickle cell crisis.
D. Ineffective Tissue Perfusion related to vascular occlusion is the most appropriate nursing diagnosis for a patient with sickle cell disease in crisis. Sickle cell crisis involves the occlusion of blood vessels by sickled cells, leading to impaired tissue perfusion and potential organ damage.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
A. Feeling for changes in the underarm area is important as breast tissue extends into this region and lumps can form there.
B. Since menopausal women do not have periods, they can perform BSE at any consistent time each month to help remember to do it regularly.
C. Pressing the breasts too firmly could cause discomfort and is not necessary for detecting lumps.
D. Performing BSE in the shower is effective because the soapy water allows the fingers to move smoothly over the skin.
E. Using fingertips is the proper technique for checking breasts, as it allows for more sensitivity in detecting changes in the breast tissue.
Correct Answer is D
Explanation
A. Remind the client that gonorrhea is a virus, therefore it cannot be cured. Gonorrhea is a bacterial infection caused by Neisseria gonorrhoeae and can be treated with antibiotics.
B. Instruct the client about preventing reinfection by using a diaphragm. While diaphragms can be a method of contraception, they are not effective at preventing sexually transmitted infections like gonorrhea.
C. Check for the presence of a primary lesion or chancre. Primary lesions or chancres are associated with syphilis, not gonorrhea.
D. Obtain information about the client's recent sexual partners. It is important to obtain information about recent sexual partners to notify them and prevent the spread of the infection.
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