An older female client who resides in a long-term care facility has a male friend who often visits her in the evenings. The practical nurse (PN) enters the client's room to administer medications and finds the couple in bed together. What action should the PN take?

The correct answer is choice C - Paresthesia, paralysis, pedal pulses, pallor, and pain.

Choice A rationale:

Clear lung sounds, CPM (continuous passive motion) on. While assessing lung sounds and the

use of CPM after knee replacement is essential, it may not be the most critical information to document in the client's electronic medical record (EMR) compared to other potential complications.

Choice B rationale:

Call bell, side rails, bed in low position, and ambulation aids. These are important safety measures and assistive devices for the client's post-operative recovery. While documenting these measures is important, they are not the most crucial findings to be documented in the EMR.

Choice C rationale:

Paresthesia, paralysis, pedal pulses, pallor, and pain. After a total knee replacement, it is crucial to assess the neurovascular status of the affected leg to identify any potential complications like nerve damage, circulatory impairment, or blood clot formation.

Documenting these assessments in the EMR helps monitor the client's progress and identify any changes that may require immediate intervention.

Choice D rationale:

Blood pressure 138/88, pain scale 7, and respirations 22. While monitoring vital signs and pain levels is important, these parameters are not the top priority in this situation.

Neurovascular assessments are more critical for the early detection of complications.

Correct Answer: B. Joint pain.

Choice B rationale:

Joint pain is the most common symptom experienced by individuals during a sickle cell crisis. The misshapen red blood cells can block blood flow to joints, leading to severe pain and inflammation. Joint pain is a hallmark sign of a sickle cell crisis, and managing pain is a critical aspect of caring for these patients.

Choice A rationale:

Decreased hemoglobin is not the expected symptom during a sickle cell crisis. A sickle cell crisis is characterized by sudden and severe pain due to the misshapen red blood cells blocking blood flow and causing tissue damage. While a sickle cell crisis can lead to anemia, the child experiencing the crisis would be more likely to describe pain and not specifically mention decreased hemoglobin.

Choice C rationale:

Infection is not a typical symptom experienced during a sickle cell crisis. While sickle cell disease can increase the risk of infections, the crisis itself primarily manifests as acute pain due to vaso-occlusion.

Choice D rationale:

Fatigue may be experienced by individuals with sickle cell disease, especially during or after a crisis, but it is not the most likely symptom they would describe during a sickle cell crisis. The hallmark symptom of a sickle cell crisis is severe pain.