TJ, a 30-year-old client is admitted in sickle cell crisis with symptoms of dyspnea and leg pain. TJ's significant other asks, "I don't really understand why he is hurting so badly." Which of the following responses by the nurse is best?
"Clumping of abnormal red blood cells blocks the flow of blood through the capillaries."
"Bleeding in the joints occurs because red blood cells are being rapidly destroyed by the bone marrow."
"The pain is due to a disturbance in cellular metabolism."
"The bone marrow is expanding with the sickled cells and that causes pain."
The Correct Answer is A
A. This response accurately describes the pathophysiology of sickle cell crisis. During a crisis, sickled red blood cells clump together, leading to microvascular occlusion and impaired blood flow to tissues, resulting in pain.
B. Bleeding in the joints is not a characteristic feature of sickle cell crisis. It may occur in other conditions such as hemophilia or osteoarthritis but not in sickle cell crisis.
C. Disturbance in cellular metabolism is not the primary mechanism underlying the pain experienced during sickle cell crisis.
D. Bone marrow expansion with sickled cells may contribute to bone pain in sickle cell disease, but it is not the primary cause of pain during a sickle cell crisis.
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Correct Answer is D
Explanation
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.
Correct Answer is D
Explanation
A. Skin color: While changes in skin color can occur in hemochromatosis due to excess iron deposition, it is not the most important parameter to monitor for the effectiveness of deferoxamine.
B. Liver function: Liver function tests can be abnormal in hemochromatosis due to iron overload, but monitoring liver function alone may not adequately assess the effectiveness of deferoxamine in reducing iron levels.
C. Hematocrit: Hematocrit measures the proportion of blood that is made up of red blood cells and may be elevated in hemochromatosis, but it is not the primary parameter to monitor the effectiveness of deferoxamine.
D. Serum iron level: Serum iron level is the most direct indicator of iron overload and the effectiveness of deferoxamine in chelating and removing excess iron from the body.
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