Nokea
A 14 year-old with a history of sickle cell disease is admitted to the hospital with a diagnosis of vaso-occlusive crisis. Which statements by the client would be most indicative of the etiology of this crisis?
- A. I knew this would happen. I've been eating too much red meat lately.'
- B. I really enjoyed my fishing trip yesterday. I caught two fish.'
- C. I have really been working hard practicing basketball.'
- D. I went to get a cold checked out last week, and I have gotten worse.'
Correct Answer: D
Rationale: I went to get a cold checked out last week, and I have gotten worse.' Any condition that increases the body's need for oxygen or alters the transport of oxygen, such as infection, trauma or dehydration may result in a sickle cell crisis.
You may also like to solve these questions
A client is being maintained on heparin therapy for deep vein thrombosis (DVT). The nurse must closely monitor which of the following laboratory values?
- A. bleeding time
- B. platelet count
- C. activated PTT
- D. clotting time
Correct Answer: C
Rationale: activated PTT. Heparin is used to prevent further clots from being formed and to prevent the present clot from enlarging. The Activated Prothromboplastin Time (APTT) test is a highly sensitive test to monitor the client on heparin.
A nurse is providing care to a 17 year-old client in the post-operative care unit (PACU) after an emergency appendectomy. Which finding is an early indication that the client is experiencing poor oxygenation?
- A. Abnormal breath sounds
- B. Cyanosis of the lips
- C. Increasing pulse rate
- D. Pulse oximeter reading of 92%
Correct Answer: C
Rationale: The earliest sign of poor oxygenation is an increasing pulse rate as a part of the body's compensatory mechanism. Abnormal breath sounds and cyanosis are late signs of poor oxygenation. A pulse oximetry reading of 92% is normal.
As part of an infection-control policy, newly admitted clients are screened for possible undiagnosed or unsuspected infectious tuberculosis. Which questions should the nurse ask to accomplish this screening? Select all that apply.
- A. "Have you been exposed to someone with tuberculosis?"
- B. "What was the date of your last tuberculin skin test?"
- C. "Have you had a cough that lasted more than 3 weeks?"
- D. "Have you experienced blood in your urine or stools?"
- E. "Have you had a recent weight gain, fever, or night sweats?"
Correct Answer: A,B,C
Rationale: A: Exposure history is key for TB screening. B: Recent skin tests indicate prior screening. C: Prolonged cough is a TB symptom. D: Blood in urine/stools is unrelated. E: Weight loss, not gain, is associated with TB.
The client is admitted with a tentative diagnosis of hepatitis. The nurse determines that which client statement would be consistent with hepatitis?
- A. "I've not been sleeping well; I've heartburn at night that wakes me."
- B. "Whenever I eat dairy products I have diarrhea for a few days."
- C. "Lately I've been short of breath when walking short distances."
- D. "I am a smoker, but lately I can't tolerate the taste of cigarettes."
Correct Answer: D
Rationale: D: Distaste for cigarettes reflects anorexia, a common hepatitis symptom. A: Heartburn suggests GERD. B: Diarrhea with dairy indicates lactose intolerance. C: Shortness of breath is unrelated to hepatitis.
An 85 year-old client complains of generalized muscle aches and pains. The first action by the nurse should be
- A. assess the severity and location of the pain
- B. obtain an order for an analgesic
- C. reassure him that this is not unusual for his age
- D. encourage him to increase his activity
Correct Answer: A
Rationale: assess the severity and location of the pain. Most older adults have 1 or more chronic painful illnesses, and in fact, they often must be asked about discomfort (rather than 'pain') to reveal the presence of pain. There is no evidence that pain of older adults is less intense, and it is necessary for the nurse to assess the pain thoroughly before implementing pain relief measures.