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A nurse is planning the care of a patient with a diagnosis of sickle cell disease who has been admitted for the treatment of an acute vaso-occlusive crisis. What nursing diagnosis should the nurse prioritize in the patient's plan of care?
- A. Risk for disuse syndrome related to ineffective peripheral circulation
- B. Functional urinary incontinence related to urethral occlusion
- C. Ineffective tissue perfusion related to thrombosis
- D. Ineffective thermoregulation related to hypothalamic dysfunction
Correct Answer: C
Rationale: There are multiple potential complications of sickle cell disease and sickle cell crises. Central among these, however, is the risk of thrombosis and consequent lack of tissue perfusion. Sickle cell crises are not normally accompanied by impaired thermoregulation or genitourinary complications. Risk for disuse syndrome is not associated with the effects of acute vaso-occlusive crisis.
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The medical nurse is aware that patients with sickle cell anemia benefit from understanding what situations can precipitate a sickle cell crisis. When teaching a patient with sickle cell anemia about strategies to prevent crises, what measures should the nurse recommend?
- A. Using prophylactic antibiotics and performing meticulous hygiene
- B. Maximizing physical activity and taking OTC iron supplements
- C. Limiting psychosocial stress and eating a high-protein diet
- D. Avoiding cold temperatures and ensuring sufficient hydration
Correct Answer: D
Rationale: Keeping warm and providing adequate hydration can be effective in diminishing the occurrence and severity of attacks. Hygiene, antibiotics, and high protein intake do not prevent crises. Maximizing activity may exacerbate pain and be unrealistic.
A nurse is caring for a patient who has sickle cell anemia and the nurses assessment reveals the possibility of substance abuse. What is the nurses most appropriate action?
- A. Encourage the patient to rely on complementary and alternative therapies.
- B. Encourage the patient to seek care from a single provider for pain relief.
- C. Teach the patient to accept chronic pain as an inevitable aspect of the disease.
- D. Limit the reporting of emergency department visits to the primary health care provider.
Correct Answer: B
Rationale: The patient should be encouraged to use a single primary health care provider to address health care concerns. Emergency department visits should be reported to the primary health care provider to achieve optimal management of the disease. It would be inappropriate to teach the patient to simply accept his or her pain. Complementary therapies are usually insufficient to fully address pain in sickle cell disease.
A client with several chronic health problems has been newly diagnosed with a qualitative platelet defect. What component of the patient's previous medication regimen may have contributed to the development of this disorder?
- A. Calcium carbonate
- B. Vitamin B12
- C. Aspirin
- D. Vitamin D
Correct Answer: C
Rationale: Aspirin may induce a platelet disorder. Even small amounts of aspirin reduce normal platelet aggregation, and the prolonged bleeding time lasts for several days after aspirin ingestion. Calcium, vitamin D, and vitamin B12 do not have the potential to induce a platelet defect.
A patient has been living with a diagnosis of anemia for several years and has been experiencing recent declines in hemoglobin levels despite ongoing treatment. Which of the following findings would indicate complications from anemia?
- A. Venous ulcers and visual disturbances
- B. Fever and signs of hyperkalemia
- C. Epistaxis and gastroesophageal reflux
- D. Ascites and peripheral edema
Correct Answer: D
Rationale: A significant complication of anemia is heart failure from chronic diminished blood volume and the heart's compensatory effort to increase cardiac output. Patients with anemia should be assessed for signs and symptoms of heart failure, including ascites and peripheral edema. None of the other listed signs and symptoms is characteristic of heart failure.
The nurse on the pediatric unit is caring for a patient with a diagnosis of hemophilia. The patient is a childâ??a 10-year-old boy. The nurse knows that a priority nursing diagnosis for this patient would be what?
- A. Hypothermia
- B. Diarrhea
- C. Ineffective coping
- D. Imbalanced nutrition
Correct Answer: C
Rationale: Most patients with hemophilia are diagnosed as children. They often require assistance in coping with the condition because it is chronic, places restrictions on their lives, and is an inherited disorder that can be passed to be passed to future generations. Children with hemophilia are not at risk of hypothermia, diarrhea or imbalanced nutrition.