Nokea
Which nursing diagnosis should the nurse expect to see in a plan of care for a client in sickle cell crisis?
- A. Imbalanced nutrition:Less than body requirements related to poor intake
- B. Disturbed sleep pattern related to external stimuli
- C. Impaired skin integrity related to pruritus
- D. Pain related to sickle cell crisis
Correct Answer: D
Rationale: Sickle cell crisis is characterized by intense pain due to the vaso-occlusive properties of sickled red blood cells leading to tissue ischemia. Therefore, pain is the primary nursing diagnosis that the nurse should expect to see in the plan of care for a client experiencing a sickle cell crisis. Managing and alleviating the pain is a priority in the care of these clients to improve quality of life and prevent complications. Other nursing diagnoses such as imbalanced nutrition, disturbed sleep pattern, and impaired skin integrity may not be directly related to the acute crisis and would not be the priority focus of care in this situation.
You may also like to solve these questions
A 62-year old client diagnosed with pyelonephritis and possible septicemia has had five urinary tract infections over the past 2 years. She's fatigued from lack of sleep; urinates frequently, even during the night, and has lost weight recently. Tests reveal the following: sodium level 152mEq/L, osmolarity 340mOsm/L, glucose level 125mg/dl, and potassium level of 3.8mEq/L. Which of the following nursing diagnoses is most appropriate for this client?
- A. Deficient fluid volume related to inability to conserve water
- B. Imbalanced nutrition: Less than body requirements related to hypermetabolic state
- C. Deficient fluid volume related to osmotic diuresis induced by hypernatremia
- D. Imbalanced nutrition: Less than body requirements related to catabolic effects of insulin deficiency
Correct Answer: C
Rationale: The client's elevated sodium level of 152 mEq/L indicates hypernatremia, which can lead to osmotic diuresis, causing excessive urination and subsequent fluid loss. This fluid loss can result in deficient fluid volume. The client's symptoms of frequent urination, fatigue from lack of sleep, and weight loss are indicative of dehydration due to the osmotic diuresis. Therefore, the most appropriate nursing diagnosis for this client is Deficient fluid volume related to osmotic diuresis induced by hypernatremia.
A client with Hashimoto's thyroiditis and a history of two myocardial infarctions and coronary artery disease is to receive levothyroxine (Synthroid). Because of the client's cardiac history, the nurse would expect that the client's initial dose for the thyroid replacement would be which of the following?
- A. 25 g/day, initially
- B. Delayed until after thyroid surgery
- C. 100 g/day, initially
- D. Initiated before thyroid surgery
Correct Answer: A
Rationale: In a client with a history of two myocardial infarctions and coronary artery disease, initiating levothyroxine therapy with a low starting dose of 25 mcg/day is recommended. Thyroid hormone replacement therapy can potentially worsen underlying cardiac conditions, so a cautious approach is necessary. The dose may be gradually titrated upwards based on thyroid function tests and the client's response. Delaying treatment until after thyroid surgery (option B) is not necessary in this scenario if the client requires thyroid hormone replacement. Initiating levothyroxine before thyroid surgery (option D) is not relevant to the given clinical situation. Starting with a higher dose of 100 mcg/day (option C) may pose a higher risk of cardiac complications in this client with a cardiac history.
A client requires minor surgery for removal of a basal cell tumor. The anesthesiologist administers the anesthetic ketamine hydrochloride (Ketalar), 60g IV. After Ketamine administration, the nurse should monitor the client for:
- A. Muscle rigidity and spasms
- B. Hiccups
- C. Extrapyramidal reactions
- D. Respiratory depression
Correct Answer: A
Rationale: Ketamine hydrochloride (Ketalar) is a dissociative anesthetic that can cause muscle rigidity and spasms as a side effect. This is known as a dose-dependent reaction to ketamine administration. Monitoring for muscle rigidity and spasms is important to ensure the client's safety and to provide appropriate management if this adverse effect occurs. It is essential for the nurse to closely observe the client for any signs of muscle rigidity and spasms after the administration of ketamine.
Which of the ff does the examiner note when auscultating the lungs of a client with pleural effusion?
- A. Pronounced breath sounds
- B. Expiratory wheezes
- C. Friction rub
- D. Fluid in the involved area
Correct Answer: D
Rationale: When auscultating the lungs of a client with pleural effusion, the examiner would note sounds consistent with fluid accumulation in the pleural space. This includes decreased or absent breath sounds over the area where the effusion is present. The presence of fluid in the involved area may cause a dullness to percussion as well. Pronounced breath sounds and expiratory wheezes are not typically associated with pleural effusion. While a friction rub may be heard in conditions such as pleurisy, it is not specific to pleural effusion.
Joel's parents ask if-their other children will be affected by the disorder. Which of the following statements should guide the nurse in her response? a.All the girls will be normal and the other son a carrier
- A. All the girls will be carriers and one half the boys will be affected
- B. Each son has a chance of being affected and each daughter a 50% chance of being a carrier
- C. Each son has 50% chance of being affected or a carrier, and the girls will be all carriers.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.