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
Explanation
A. Prolonged bleeding or easy bruising is a characteristic feature of hemophilia, a genetic
disorder characterized by deficient or defective blood clotting proteins, leading to impaired blood clotting and prolonged bleeding after injury or trauma.
B. Excessive blood clotting is not a characteristic feature of hemophilia; rather, it is the opposite.
Hemophilia is characterized by a deficiency in clotting factors, which results in impaired clot formation.
C. Hemophilia does not typically result in increased platelet count. Platelets are involved in the initial stages of blood clotting, but hemophilia primarily affects clotting factor proteins.
D. Delayed wound healing is not a characteristic feature of hemophilia. Hemophilia primarily affects blood clotting, leading to prolonged bleeding, but it does not directly affect wound
healing processes.
Correct Answer is B
Explanation
A. Tamoxifen: Tamoxifen is primarily used in the treatment of breast cancer, not prostate cancer.
B. Leuprolide: Leuprolide is a gonadotropin-releasing hormone (GnRH) agonist commonly used in the treatment of advanced prostate cancer to reduce testosterone levels, slowing the growth of cancer cells.
C. Cyclophosphamide: Cyclophosphamide is a chemotherapy drug used to treat various types of cancer but is not commonly used specifically for prostate cancer.
D. Finasteride: Finasteride is a 5-alpha-reductase inhibitor used to treat benign prostatic hyperplasia (BPH) and male pattern baldness but is not typically used in the treatment of advanced prostate cancer.
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