Difficulty: Medium
Average Score: 93%
Simulated
Passage / Scenario
Nurses Notes0800:
Client reports fatigue, muscle weakness, joint pain, and dyspnea. Sclerae is jaundiced. 2.5 cm (1 in) by 2.5 cm (1 in) open ulcer noted on inner left ankle.
Vital Signs
0800:
ÔÇó Temperature 37.5┬░ C (99.5┬░ F)
ÔÇó Blood pressure 122/68 mm Hg
ÔÇó Heart rate 95/min
ÔÇó Respiratory rate 28/min
ÔÇó Oxygen saturation 95% on room air
1000:
ÔÇó Temperature 37.5┬░ C (99.5┬░ F)
ÔÇó Blood pressure 88/56 mm Hg
ÔÇó Heart rate 112/min
ÔÇó Respiratory rate 26/min. labored
ÔÇó Oxygen saturation 90% on room air
Diagnostic Results
1000:
Hct 26% (37% to 47%)
Hgb 8 g/dL (12 to 16 g/dL)
A nurse is caring for a client who has sickle cell disease. For each client finding, click to specify if the finding is consistent with sickle cell disease, iron deficiency anemia. or leukemia. Each finding may support more than 1 disease process.
Correct answer
A,B,C,D,E
Rationale
Jaundice is due to hemolysis in sickle cell disease. Respiratory issues occur in sickle cell (acute chest syndrome) and leukemia (bone marrow infiltration). Ankle ulcers are common in sickle cell due to poor circulation. Joint pain occurs in sickle cell (vaso-occlusive crises) and leukemia (bone marrow infiltration). Tachycardia is seen in all three due to anemia or systemic effects.