An 18-year-old patient with a known history of sickle cell anemia presents to the emergency department with severe pain in the lower back and joints, fever, and signs of dehydration. What is the most appropriate initial nursing intervention?
Administer intravenous fluids and pain management as prescribed.
Apply cold compresses to the painful areas to reduce inflammation.
Administer antibiotics immediately to treat the underlying infection.
Encourage the patient to perform light exercise to promote circulation.
The Correct Answer is A
Choice A Reason:
Administering intravenous fluids and pain management is the most appropriate initial intervention for a patient with sickle cell anemia presenting with severe pain, fever, and dehydration. Sickle cell crises often lead to severe pain due to vaso-occlusion, where sickled red blood cells block blood flow to various parts of the body. Intravenous fluids help to rehydrate the patient and reduce blood viscosity, which can alleviate the vaso-occlusive crisis. Pain management is crucial to provide relief and improve the patient’s comfort. This approach addresses the immediate symptoms and stabilizes the patient.
Choice B Reason:
Applying cold compresses to the painful areas is not recommended for patients with sickle cell anemia. Cold can cause vasoconstriction, which may worsen the vaso-occlusion and increase pain. Instead, warm compresses are often suggested to help dilate blood vessels and improve blood flow.
Choice C Reason:
Administering antibiotics immediately is not the primary intervention unless there is a clear indication of an infection. While fever can be a sign of infection, it can also occur due to the inflammatory response associated with a sickle cell crisis. The priority is to manage pain and dehydration first, and then evaluate the need for antibiotics based on clinical findings.
Choice D Reason:
Encouraging the patient to perform light exercise is not appropriate during an acute sickle cell crisis. Physical activity can increase oxygen demand and exacerbate the pain and vaso-occlusion. Rest and adequate hydration are more suitable to manage the crisis effectively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: Instruct the patient to elevate the arm above the heart immediately after the procedure
Elevating the arm above the heart can help reduce blood flow to the area, potentially minimizing bleeding. However, this method alone is not sufficient to ensure proper hemostasis, especially in patients with thrombocytopenia. Applying direct pressure to the puncture site is more effective in stopping bleeding and preventing hematoma formation.
Choice B: Apply firm pressure to the site for at least 10 minutes after the procedure
Applying firm pressure to the venipuncture site is crucial in patients with thrombocytopenia to ensure proper clotting and prevent bleeding. This method helps in forming a stable clot at the puncture site, reducing the risk of prolonged bleeding and hematoma formation. Given the patient’s low platelet count, maintaining pressure for an extended period is essential to achieve hemostasis.
Choice C: Avoid using a tourniquet during the procedure
While avoiding a tourniquet might seem beneficial to reduce pressure on the veins, it is not a standard practice to minimize bleeding risk in thrombocytopenic patients. Tourniquets are typically used to make veins more prominent for easier access during venipuncture. The key to minimizing bleeding is proper post-procedure care, such as applying firm pressure to the site.
Choice D: Use a larger gauge needle to ensure quicker blood flow
Using a larger gauge needle is not advisable for patients with thrombocytopenia. Larger needles can cause more trauma to the vein, increasing the risk of bleeding and hematoma formation. Instead, using the smallest gauge needle that can effectively draw blood is recommended to minimize vein damage.
Correct Answer is B
Explanation
Choice A Reason:
Increased appetite is not typically associated with anemia. Anemia generally leads to symptoms related to decreased oxygen-carrying capacity of the blood, such as fatigue, weakness, and shortness of breath. Increased appetite is more commonly linked to other conditions, such as hyperthyroidism or certain metabolic disorders.
Choice B Reason:
Fatigue is a common and significant symptom of anemia. When hemoglobin levels are low, the body’s tissues do not receive adequate oxygen, leading to feelings of tiredness and exhaustion. This is because hemoglobin is responsible for transporting oxygen from the lungs to the rest of the body. In anemia, the reduced oxygen delivery results in decreased energy levels and persistent fatigue.
Choice C Reason:
Weight gain is not typically associated with anemia. In fact, some forms of anemia, such as those caused by chronic diseases or malnutrition, may lead to weight loss rather than gain. Weight gain can be associated with other health issues, such as hypothyroidism or fluid retention, but not directly with anemia.
Choice D Reason:
Hypertension is not a common manifestation of anemia. Anemia usually leads to symptoms like pallor, shortness of breath, and fatigue due to the reduced oxygen-carrying capacity of the blood. Hypertension, or high blood pressure, is more commonly associated with cardiovascular diseases, kidney disorders, or endocrine conditions.
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