(Select all that apply):
A nurse is performing a comprehensive assessment of a patient with SCD.
Which aspects of the nursing assessment should the nurse prioritize?
Gathering information about the patient's personal and family history of SCD or trait.
Assessing the location, intensity, and duration of pain.
Measuring the patient's temperature, pulse, and blood pressure.
Inspecting for signs of anemia and jaundice during the physical examination.
Conducting genetic testing to confirm the diagnosis of SCD.
Correct Answer : A,B,D
Choice A rationale:
Gathering information about the patient's personal and family history of SCD or trait.
Rationale: Understanding the patient's personal and family history of SCD or the sickle cell trait is crucial in assessing the risk and potential complications associated with the disease.
It helps identify genetic factors, family support, and the likelihood of the patient experiencing complications related to SCD.
Choice B rationale:
Assessing the location, intensity, and duration of pain.
Rationale: Pain is a hallmark symptom of SCD, and assessing the location, intensity, and duration of pain is essential in managing and monitoring the patient's condition.
This information helps healthcare providers determine the severity of the pain crisis, make treatment decisions, and assess treatment effectiveness.
Choice D rationale:
Inspecting for signs of anemia and jaundice during the physical examination.
Rationale: Anemia and jaundice are common clinical manifestations of SCD.
Anemia results from the destruction of sickled red blood cells, while jaundice occurs due to the breakdown of these cells and the release of bilirubin.
Assessing for signs of anemia and jaundice, such as pallor and yellowing of the skin and sclera, is essential in monitoring the patient's overall health.
Choice C rationale:
Measuring the patient's temperature, pulse, and blood pressure.
Rationale: While vital signs are important components of a nursing assessment, they are not specific to sickle cell disease.
Monitoring vital signs is a routine practice in healthcare but may not provide specific information about the disease's complications or progression.
Choice E rationale:
Conducting genetic testing to confirm the diagnosis of SCD.
Rationale: Genetic testing is essential for diagnosing sickle cell disease, but it is typically performed before the patient is confirmed to have SCD.
Once a diagnosis is established, genetic testing may not be necessary for routine assessment.
It is crucial in the initial diagnostic phase but is not a part of ongoing nursing assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Sickle cell disease (SCD) is a genetic disorder caused by a mutation in the HBB gene, leading to the production of abnormal hemoglobin called hemoglobin S (HbS)
This abnormal hemoglobin causes red blood cells to become sickle-shaped when exposed to low oxygen levels, which is a hallmark of SCD.
The nurse's response accurately reflects the genetic basis of this condition.
Choice B rationale:
This choice is incorrect.
Sickle-shaped red blood cells in SCD are not the result of an autoimmune reaction.
Choice C rationale:
This choice is incorrect.
Sickle-shaped red blood cells are not caused by a viral infection.
Choice D rationale:
This choice is incorrect.
Diet and lifestyle choices do not contribute to the sickle shape of red blood cells in SCD.
Correct Answer is A
Explanation
Choice A rationale:
Monitoring for signs of transfusion reaction is a critical nursing responsibility during and after a blood transfusion.
Transfusion reactions, such as fever, chills, rash, or dyspnea, can occur due to various factors, including compatibility issues or bacterial contamination of the blood product.
Detecting these signs promptly allows for immediate intervention, including stopping the transfusion and providing appropriate treatment.
This ensures the patient's safety and well-being during the transfusion process.
Choice B rationale:
Monitoring the patient's response to music therapy is not a standard nursing assessment during or after a blood transfusion.
While music therapy can have benefits in managing pain and anxiety, it is not directly related to the safety of the transfusion process.
Choice C rationale:
Monitoring the patient's fluid intake and output is essential in many clinical situations, but it is not specifically related to the safety of a blood transfusion.
This parameter is more relevant in assessing the patient's hydration status and renal function.
Choice D rationale:
Monitoring the patient's emotional state is important for overall patient care, but it is not a primary concern during and immediately after a blood transfusion.
The focus during this time should be on detecting any adverse reactions or complications related to the transfusion itself.
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