The nurse is caring for a patient in sickle cell crisis. What is the rationale for providing warm compresses and blankets for this patient?
Heat relaxes the muscles and distracts the patient from the pain.
Sickle cell crisis pain can be exacerbated with shivering.
Heat promotes proper formation of red blood cells (RBCs) and prevents sickling.
Heat increases circulation by preventing vasoconstriction.
The Correct Answer is D
A. Heat relaxes the muscles and distracts the patient from the pain. While warmth can provide comfort, the main goal is to improve circulation rather than distraction.
B. Sickle cell crisis pain can be exacerbated with shivering. Although shivering may be uncomfortable, it is not the primary reason for using heat during a sickle cell crisis.
C. Heat promotes proper formation of red blood cells (RBCs) and prevents sickling. Heat does not affect RBC formation or prevent sickling. The condition of sickling is due to genetic factors, not temperature.
D. Heat increases circulation by preventing vasoconstriction. In sickle cell crisis, warmth helps prevent vasoconstriction, which can reduce blood flow to areas already compromised by sickled cells. Preventing vasoconstriction may help alleviate pain and improve circulation.
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Correct Answer is D
Explanation
A. Pulmonary congestion: Pulmonary congestion is associated more with fluid overload or transfusion-associated circulatory overload (TACO), not an acute hemolytic reaction.
B. Urticaria: Urticaria (hives) is more typical of a mild allergic reaction rather than an acute hemolytic reaction.
C. Vomiting: Although nausea and vomiting may occur in various transfusion reactions, it is not specific to an acute hemolytic reaction like low back pain is.
D. Low back pain: Low back pain, often around the kidneys, is a classic sign of an acute hemolytic reaction due to the breakdown of RBCs and the release of hemoglobin into the bloodstream, which can lead to renal damage. This reaction is a medical emergency requiring immediate intervention.
Correct Answer is A
Explanation
A. The spleen is the primary site for platelet destruction. In ITP, the spleen often sequesters and destroys platelets, leading to low platelet levels. Removing the spleen reduces platelet destruction and can help increase platelet counts in affected patients.
B. The spleen is at risk for infection due to the critical loss of WBCs. While infection risk increases after splenectomy, this is not the rationale for the procedure. The spleen does play a role in immune function, but splenectomy is indicated for reducing platelet destruction, not infection prevention.
C. Your spleen is making too many platelets. The spleen does not produce platelets; rather, it filters and sometimes destroys them, particularly in ITP. This choice does not accurately reflect the pathophysiology of ITP.
D. The spleen causes an overabundance of immature platelets. The spleen does not cause an increase in immature platelets. In ITP, platelets are destroyed, not overproduced.