The mother of a teenage boy with sickle cell anemia asks the nurse why her son has such horrible pain during a sickle cell crisis. Which of the following is the best response by the nurse?
"Dehydration Is the primary reason for the pain that is experienced during a sickle cell crisis; try to increase your son's fluid intake."
"We really don't know what causes the pain that is experienced during a sickle cell crisis."
"Sickled cells get clogged in the blood vessels, preventing blood from getting to the tissues, which causes the severe pain of a crisis."
"You will need to discuss this with your doctor. I cannot explain why this pain occurs to your son."
The Correct Answer is C
A. "Dehydration Is the primary reason for the pain that is experienced during a sickle cell crisis; try to increase your son's fluid intake."
This response is not the best choice because while dehydration can indeed exacerbate sickle cell crises and lead to complications, it is not the primary reason for the pain experienced during a sickle cell crisis. The severe pain during a crisis is primarily due to vaso-occlusion, where sickled red blood cells block blood flow in the small blood vessels, leading to tissue ischemia and pain. While adequate hydration is important in managing sickle cell disease, it alone does not address the underlying cause of the pain during a crisis.
B. "We really don't know what causes the pain that is experienced during a sickle cell crisis."
This response is not accurate and not the best choice because the medical community does understand the underlying cause of pain during a sickle cell crisis. It is primarily due to vaso-occlusion, as mentioned earlier, where sickled red blood cells block blood flow in the blood vessels.
C. "Sickled cells get clogged in the blood vessels, preventing blood from getting to the tissues, which causes the severe pain of a crisis."
This response is the best choice because it provides an accurate and clear explanation of why individuals with sickle cell anemia experience severe pain during a sickle cell crisis. It addresses the underlying mechanism of vaso-occlusion, where sickled red blood cells block blood flow in the small blood vessels, leading to tissue ischemia and severe pain.
D. "You will need to discuss this with your doctor. I cannot explain why this pain occurs to your
son."
This response is not the best choice because the nurse should be able to provide basic information about the disease and its symptoms to the mother. It's important for healthcare professionals to educate patients and their families about their condition to improve understanding and facilitate better management and coping strategies.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Ribs: Ribs are not typically used for bone marrow aspiration procedures due to the difficulty of accessing bone marrow in this area.
B. Humerus: While bone marrow aspiration can technically be performed in the humerus (upper arm bone), it is not commonly used as a primary site because other sites like the iliac crest offer easier access and a larger volume of bone marrow.
C. Femur: The femur (thigh bone) is a potential site for bone marrow aspiration, especially in certain situations or specific patient populations. However, it is less commonly used compared to the iliac crest.
D. Iliac crest: The iliac crest is a primary site for bone marrow aspiration due to its accessibility, the relatively low risk of complications, and the ability to obtain an adequate sample of bone marrow for diagnostic purposes.
Correct Answer is B
Explanation
A. Notify the blood bank of the discrepancy:
This choice suggests that there is a discrepancy between the blood type of the unit on hand (type B) and the client's blood type (type AB). However, in reality, there is no discrepancy in this case because individuals with type AB blood are universal recipients and can receive blood from donors of any blood type, including type B. Therefore, there is no need to notify the blood bank of any discrepancy.
B. Administer the blood as ordered:
This choice is the correct action. Type AB individuals are known as universal recipients because they can safely receive blood from donors of any blood type (A, B, AB, or O) without causing a major transfusion reaction. Since the client has type AB blood and the unit of blood on hand is type B, the nurse can administer the blood as ordered without concerns about blood type compatibility.
C. Complete an incident report:
Completing an incident report is typically done when an unexpected event or error occurs during patient care. In this scenario, there is no error or unexpected event related to blood type compatibility, so there is no need to complete an incident report.
D. Contact the provider for further orders:
Contacting the provider for further orders would be necessary if there were a specific reason or concern related to the blood transfusion that requires clarification or additional instructions. However, in this case, there are no issues with blood type compatibility, so contacting the provider is not necessary.
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