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 B
Explanation
A. Have the patient take a number and stay in the waiting area. Delaying care could lead to worsening of a potentially life-threatening bleeding episode. Hemophilia patients should be assessed promptly.
B. Place the patient in an examination room immediately and notify the physician of a potential bleeding crisis. Hemophilia patients are at risk of internal bleeding, which may not always be visible externally. Rapid assessment is essential to prevent complications from internal bleeding.
C. Send the patient for routine x-rays to locate the source of bleeding and place him in an examination room. X-rays may not immediately detect bleeding in soft tissues. The physician should evaluate the patient first.
D. Palpate the suspected area of bleeding for tenderness and edema. Palpating could worsen bleeding or cause pain, and the nurse should focus on ensuring the patient is seen promptly by the physician.
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.