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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Related Questions
Correct Answer is C
Explanation
A. Urinary hesitancy and frequency can occur with genital herpes due to the pain and discomfort of the lesions, but these are not the primary manifestations.
B. Vaginal bleeding is not a typical symptom of genital herpes.
C. Vesicles and lesions on the labia are characteristic symptoms of genital herpes, appearing as painful blisters that eventually ulcerate.
D. Vaginal drainage with a fishy odor is typically associated with bacterial vaginosis, not genital herpes.
Correct Answer is A
Explanation
A. Abnormal vaginal bleeding. Abnormal vaginal bleeding, especially postmenopausal bleeding, is the most common symptom reported by clients being evaluated for endometrial cancer.
B. Recurrent urinary tract infections. This is not a common symptom of endometrial cancer.
C. Hot flashes. Hot flashes are typically associated with menopause and hormone changes, not endometrial cancer.
D. Blood in the stool. Blood in the stool is more commonly associated with gastrointestinal issues or colorectal cancer, not endometrial cancer.
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