nclex review 3 Flashcards

Standardized Tests
Terms Definitions
WBC
5-10
Mg
1.6-2.6
Mononucleosis
Standard precautions
Epiglottis: S/S
Difficulty swallowing
normal ALT
8-20 U/L
S4
A-Stiff-Wall
Ta-Lub-Dub
-MI, Valve flutter
-Soft sound before S1
Cocaine withdrawal: S/S
Severe cravings
Depression
Fatigue
Hypersomnia
terbutaline (Brethine): Fetal S/S
Tachycardia
Hypoglycemia
Meniere's Disease:Intervention
Change positions slowly
Cushing Syndrome: S/S
Hypernatremia
Buffalo hump
Hyperglycemia
Weight gain
Moon face
Purple striae
Osteoporosis
Mood swings
Susceptiblity to infections
Hyperthermia: S/S
Increases oxygenation requirements
Increased respiratory rate and tachycardia
T wave
*repolarization of ventricles
*consists of absolute refractory period (1st half of T wave) and relative refractory period (2nd half of T wave)
*during 2nd half heart is more vulnerable to ventricular tachycardia or fibrillation if an early ectopic beat (premature ventricular contraction ) occurs
Droplet Precautions: Diseases
diptheria
streptococcal pharyngitis
pneumonia or meningitis caused by N. meningitidis
or H. influenzae Type B
mumps
aPTT-Heparin
Antidote: Protamine Sulfate
30-50
TR: 1.5-2.5
RESOLVE
support group for infertile couples
Pain
Characteristic of inflammation and infection
normal Potassium
3.5 - 5.0 mEq/L
Solitary play
Describes play for infant
prochlorperazine (Compazine): S/E
Antiemetic
Drowsiness
Orthostatic hypotension
Panic attack: S/S
Palipatations
Decreased perceptual field
Diaphoresis
Fear of going crazy
Secondary care
Prevetion of disease complications
Normal Blood Ph
7.35 - 7.45
Platelets
150,000-400,00 1. decreased platelets thrombocytopenia associated w/bleeding
Command hallucinations
involve client hearing auditory hallucinations that are telling them to do somethine, kill someone
Fluid excess: S/S
Orthopnea, dyspnea, crackles
Decrease IV fluids
Notify physician
Cushing Syndrome: Description
Hypersecretion of adrenal hormones
Impetigo
Honey crusted lesion below nose
Highly infectious superficial bacterial infection
Notify parents so they can call doctor
Treated with systemic antibiotics and antibacterial soap
Loosen scab with Burrow's soution compress, gently remove, topical ointment
Infant normal blood pressure
60/40 - 80/50
biperiden (Akineton)
Antiparkinson agent
Used to counteract extrapyramidal S/E
promethanzine (Phenergan)
H1 receptor blocker
used as antiemetic
Vomiting: Contraindicated
Contraindicated when child ingests hydrocarbons (lighter fluid) because of danger of aspiration
Addison's Disease: S/S
"eternal tan"
increase in melanocyte-stimulating hormone
Standard Precautions
barrier, used with all patients
handwashing
gloves
masks, eye protection, face shield - sprays or splashes
gowns - sprays or splashes
Daily requirement of iron: women
15 mg/day
Anemia
Decreased RBC
Causes heart rate and respirations to increase
Cardiac output will increase due to decreased oxygenation caused by anemia
Schizophrenia
Client laughs while talking about being raped
Inappropriate affect
Expressions of feelings bizzare for situation
Palpation of chest
Smooth symetrical chest expansions
Serum protein
Decreased in chronic renal failure
Normal is 6.0 - 8.0 g/dL
Placenta previa
Can't deliver vaginally
Prepare for immediate C-section
psychoanalytic therapies
empahsis on insight important
eg. patient's insight into depression
Thumb sucking
Normal behavior
Peaks at 18-20 months
Most prevelent when child is hungry or tired
Malocculsion occurs if thumb sucking continues past 4 years old or when permanent teeth errupt
Rales and tachycardia
Indicate cardiovascular fluid overload
Positive Mantoux
Further testing is necessay
Make appointment for X-ray
Dopaminergic Therapy Examples
levodopa (Sinemet), bromocriptine (Parlodel), amantadine (Symmetrel)
What is the normal PaO2 value?
80-100
true
partial seizures are produced (at least initially) by electrical impulses in a relatively small part of the brain.
Tuberculosis
TB is a reportable communicable disease that is characterized by pulmonary manifestation.
Fluid Overload: S/S
Shortness of breath
Distended neck veins
Bounding pulse of 96
Bacterial Meningitis: S/S
CSF cloudy
Hgb 13
Hct 38%
WBC 18,000
Artifical passive immunity
involves injection with antibodies that were produced in another person or animal, used to protect person against serious disease
PCA: S/E
Itching common side effect of narcotics used in PCA
Low intestional obstruction: S/S
Nausea, vomiting, abdominal distention
Distention aboue level of obstruction and intially hyperactive bowel sounds
No stool, because motility distal to obstruction would cease
No diahrrea
No rectal or GI bleeding
Married minor
Considered emancipated and can sign own consent form
PSA Test
Screening for prostatic cancer
Must be drawn before digital exam, as manipulation of prostrate will abnormally increase PSA
Acute manic episode: S/S
Agitation, grandiose delusions, euphoria, difficulty concentrating
Mood of extreme euphoria and manifests by extreme levels of behavior
Bulge test
Confirms presence of fluid in knees
Client's leg should be extended and supported on bed
dopamine (Intropin)
Used for correction of hemodynamic instability as result of shock
Monitor vital signs provides most information regarding drug
Colostomy: activities
Client may resume all previous activities that the client participate in before the colostomy after appropriate healing of the stoma or incisions
Diabetic ketoacidosis
Sunken eyeballs and fruity breath odor
Treat with normal saline and regular insulin
Integrity vs. despair and disgust
Late adulthood
65 +
Cystic Fibrosis
Hereditary condition that causes the exocrine glands to malfunction. The patient produces very thick mucus that causes severe congestion within the lungs and digestive system.
Which blood type is the universal 'recipient'?
AB+
Acid
substance that releases a hydrogen ion when dissolved in water
Poison Control
P- Promote Stability asses condition and provide airway support and provide IV site if necessary
O- Off / Out wash off if radioactive remove contaminated clothing if has pill in mouth take out eyes may need to be flushed out antidotes may be necessary for drug overdose ingested substances may be taken out of body by emisis, lavadge, absorbant (activated charcoal) catharticis Emithis is contra indicated if a person is comatose in shock experience a seizure or has loss of gag reflex. If a low viscosity hydrocarbon or strong corrosive (acid or alcheine ) has been ingested immises is contra indicated
I- Identify the toxin
S- Support the client both physically and psychologically parents may feel guilty support is imperative
O- Ongoing safety education regarding poison control
N- Notify they poison control center facility or provider care for immediate consolation.
Projection
"If my wife was a better housekeeper, I wouldn't have this problem"
Duodenal ulcers: Pain
Increases 2-4 hours after meal
Mid morning and mid afternoon
Antacids may be given for duodneal ulcers
Stroke patient: communication
Speak using phrases and short sentences
Will decrease tension and anxiety in stroke patient
Patient may understand some incoming communication if it is kept simple
Speech may be relearned with appropriate supoort and interentions
TB Treatment
Necesary to take medication for 6-9 months
Airborne precautions at hospital, but can send home with family because they have already been exposed
Burn victim
Body responds to hypovolemic shock by adrenergic stimulation
Vasoconstriction compenstates for loss of fluid resulting in cool clamy skin, tachycardia, tachypnea, and pale color
Post C-section: Most life-threatening
Prevent fluid and electrolyte loss
Hemorrhage and shock are the most life-threatening conditions that occur after surgery
Dialysate solution
Temperature can be regulated with a heating pad
Warming reduces pain cause by a cold solution
Contraindicated to warm in microwave because of uneven heating pattern
Pneumonia: Therapuetic response
Thin white sputum accompanied by normal respirations
Inspection of anterior chest
Shape and configeration of chest
Facial expression
Level of consciouness
Color and condition of skin
Quality of respirations
Urinary Tract Infection: Limit what?
Milk - alkaline fluid
DVT
On bedrest for 5-7 days to prevent pulmonary embolism - be concerned if patient ambulates to bathroom
Monitor peripheral pulses
Administer anticoagulents
Elevate legs
Apply warm compress
Expected signs: pain in calf and edema
Friction rub (pleural)
*heard on inspiration and expiration over an area of inflammation
*is a harsh, grating, creaking sound
Cleft lip and palate
congenital deformity detected at birth
midline fissure or opening into palate
Patients with anorexia nervosa
experience difficulty with self-esteem and self-identity which inhibits ability to act assertively
Bulimia: S/S
Ulcerated membranes of the mouth due to frequent vomiting
Normal in appearance
Respiratory distress in children
Early: restlessness, increased RR, increase pulse rate
diaphoresis
Late: flaring nostrils, retractions, grunting, adventitious breath sounds, use of accessory muscles, head bobbing, alterations in blood gasses, cyanosis & pallor
What is the normal HCT values?
36.0 - 46.0
Base
substance that will bind to a hydrogen ion when dissolved in water
Blood Pressure
Blood Pressures- Is the force exerted by the blood against the walls of the blood vessels.
Systolic Dystolic
Normal <120 <80
Prehypertension 120-139 80-89 200/100 is stroke territory
Hypertension 140-159 90-99
Stage 1
Hypertension ≥160 ≥100
Stage 2
If the BP cuff is too small then it will give a false high reading but if the cuff is too big it will give a false low reading. Be cautious when taking BP from people who are on blood thinners. LOC is very important bc they may have normal readings but are hard to arrouse.
Respiratory/Heart Rates
Neonate R-40 HR-140
Toddler(2-4) R-30 HR-120
Child(6-10) R-20 HR-100
Adult R-12-18 HR-60-100
If a patient has a high respiratory rate they might not be exchanging air. If they are having trouble breathing they may have a scared look on their face or become restless. They my be using accessory muscles or neck muscles to help them breath.
Skin assessment determines if they r hot, dry, cold, or clammy. Is a conformation of how they feel. Touching them can show them we care about how they feel and may calm them down.
Pulse- Feeling the pulse can determine if it is irregular, regular, bounding, thready, strong, or weak. Abnormal pulse is a high nursing priority action.
Pain is known as the 5th vital sign. It may result in VS changes. When in pain their RR and pulse increases. Pulse is a good indicator of pain medication effectiveness.
diabetes mellitus type I S/S
Polyuria, Polydipisia, Polyphagia. weight loss, fatigue, ↑frequency of infection, rapid onset, insulin dependent
Tonsil and pharyngeal culture
Quickly swabbed to avoid client discomfort
Hold client head upright, not hyperextended
Normal contractions
Should be less frequent (longer than 2 minute intervals) and should be of shorter duration (less than 90 seconds)
Allows for resting time between contractions
Controlled ventilation
Delivers a set volume at a set rate
Dose not allow patient-initiated responses
Mulitple sclerosis
Overexposure to heat or cold may cause damage to changes related to sensation
Bowel perforation
When the bowel perforates as result of interluminal pressure within the gut, intestional contents are released into the peritoneum leading to peritonitis
Prepare client for emergency surgery
Client is kept in semi-Fowler position
Oral medication: Infant
Place medication in an empty nipple and allow infant to suck
Never add medication to infant formula
Never placed in reclining position during procedure due to risk of aspiration
Allergies to insulin: cause
reactions caused by perservatives in insulin
same for all types
Duodenal ulcer: S/S
Pain 3-4 hours after meal, during night, prior to ingestion of food
Continuous Bladder Irrigation
Prevents formation of clots that can lead to obstruction and spasms in post-op TURP client
Enables urine to keep flowing
Glycosylated hemoglobin
When RBC are being formed, sugar is attached (glycosylated) and remains attached throughout life of RBC
Normal is 2.5-6.0 %
Timing of test is not important
Time out/Room restriction
Might be useful strategy beore client becomes assualtive
Once client is assaultive, he may contine this behavior in his room without any redirection and support
Cranial nerves & functions
Olfactory (1) Sensory smell reception & interpretation
Optic (2) Sensory visual acuity & visual fields
Oculomotor (3) Motor raise eyelids, most extraocular movements. parasympathetic pupillary constriction change lens shape
Trochlear (4) Motor downward, inward eye movement
Trigeminal (5) Motor jaw opening & clenching, chewing & mastication. Sensory sensation to cornea, iris, lacrimal glands, conjunctiva, eyelids, forehead, nose, nasal & mouth mucosa, teeth, tongue, ear, facial skin
Abducens (6) Motor lateral eye movement
Facial (7) Motor movement of facial expression muscles except jaw, close eyes, labial speech sounds. Sensory taste=anterior 2/3rds of tongue, sensation to pharynx. Parasympathetic secretion of saliva & tears.
Acoustic (8) sensory hearing & equilibrium
Glossopharyngeal (9) motor voluntary muscles for swallowing & phonation. sensory sensation of nasopharynx, gag reflex, taste posterior 1/3rd of tongue. Parasympathetic secretion of salivary glands, carotid reflex.
Vagus (10) Motor volunatry muscles of phonation (guttural speech sounds) & swallowing. Sensory sensation behind ear & part of external ear canal. Parasympathetic secretion of digestive enzymes; peristalsis; carotid reflex; involuntary action of heart, lungs, & digestive tract.
Spinal accessory (11) motor turn head, shrug shoulders, some actions for phonation.
Hypoglossal (12) Motor tongue movement for speech sound articulation & swallowing.
Normal blood pressure in the adult is?
120/80 mm Hg
Diuretics are often prescribed for treatment of acute glomerulonephritis to treat fluid overload and hypertension. Which of the following is least likely to be prescribed for this purpose in glomerulonephritis?
(A) Bumex
(B) Lasix
(C) Demadex
(D) Aldacton
(D) Aldactone
Rationale: Loop diuretics are most commonly used to treat fluid overload and hypertension because of their effectiveness. Bumex, Lasix and Demadex are all loop diuretics. Aldactone, a potassium sparing diuretic, is very weak in comparison to loop diuretics. Unless the client's potassium level is dangerously low, this medication is not usually prescribed. Sometimes potassium sparing diuretics are used along with lower doses of other diuretics to help conserve the body's potassium levels.
A client with obsessive-compulsive disorder (OCD) is admitted to the psychiatric facility for treatment. Select all of the following that are included in medical treatment of this disorder.
(A) Prescription of selective serotonin reuptake inhibitors (SSRI
(A) Prescription of selective serotonin reuptake inhibitors
(B) Behavior therapy
Rationale: Treatment of obsessive-compulsive disorder (OCD) includes use of selective serotonin reuptake inhibitors (SSRIs) and behavior therapy. OCD is thought to be caused partially by low levels of serotonin in the brain. SSRIs increase serotonin levels. Behavior therapy involves exposure to a feared object or situation and prevention of carrying out compulsive behavior. Benzodiazepines are not prescribed to treat OCD. Imagery and distraction are relaxation techniques usually used as pain relief measures. Electroconvulsive therapy is used to treat severe depression when other treatment modalities are ineffective.
Threatened abortion: S/S
Woman at 5 weeks with vaginal spotting and some cramping
Instruct to decrease activity
Ostomy bag
Change bag at least once a week
Good time to inspect stoma
Change bag when seal around stoma is loose or leaking
Breast feeding: preparation
Wash breasts with water and rub with towel everyday
Prepares nipples for streching action of sucking during breast feeding
Soap avoided to prevent drying
Massaging breast could cause tissue to become tender
Plasma cholesterol screening
Only sips of water are permitted 12 hours before to achieve acurate results
Where are buffers located?
Chemical buffers are present in both extracellular and intracellular fluid. They are also found in all body tissues, including bone.
A clinic nurse is providing instructions to a mother of a child who was diagnosed with mumps. The mother is concerned about her other children and asks the nurse how the infection is transmitted. The nurse informs the mother that mumps is transmitted by:
2. Airborne droplets
Rationale: Mumps id transmitted via airborne droplets, salivary secretions, and possibly the urine. Options 1, 3 and 4 are incorrect.
The LPN/LVN is providing blood pressure readings at a local convenience store for members of the community. For which of the following client should the nurse recommend follow-up with the client's primary doctor within a period of two months?
(A) 114/78
(
(C) 134/97
Rationale: Normal blood pressure readings range between 100 to 140 systolic and 60 to 90 diastolic. The Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (2003) recommends that if either a systolic reading between 140 and 149 or a diastolic reading of 90 to 99 is obtained, the client's blood pressure should e rechecked in 2 months following the initial reading. The correct answer is (C). In this answer the diastolic reading is above the normal range. All other answers are within normal blood pressure range.
Rape trauma syndrome: goal
Inital priority is for client to begin dealing with what has happened by verbalizing her feelings and gaining some perspective and acceptance
Phobia patient: initall needs
Is a fixed channel for discharge of tension from unconscious conflict
Secondary gain (attention and assistance received) is not motivation of phobic patient, remain nonjudgemental
Allow client to avoid anxiety producing situations
Erikson Stage: Birth to 18th months
Trust vs Mistrust
Attachment ot the mother
Toys: mobiles, rattles, squeaking toys, picture books, balls, colored blocks & activity boxes
What is cardiac output?
Volume of blood ejected by the heart in one minute:
cardiac output = heart rate x stroke volumne
Evaluate urine specific gravity
A client with head trauma develops a urine output of 300 ml/hr, dry skin, and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially?
Damage to cranial nerve I
A 78-year-old client is admitted to the Emergency Department (ED) via emergency medical service (EMS) with complaints of severe diarrhea with resultant weakness and signs of dehydration. Discussion with the significant other reveals that the patient continually eats spoiled foods. Which of the following might be most directly related to this patient's behavior?
Mr. Sanders, an 83 year old client, presents to the clinic complaining of a persistent "whistling sound" in his ears. How would the LPN/LVN document this complaint in the medical record?
Answer: Tinnitus
Rationale: Tinnitus is defined as a sound heard in one or both ears. The sound could be described as ringing, buzzing or whistling and occurs without an external stimulus. Causes of tinnitus include an ear infection, side effects of certain medications, a blockage in the eustachian tube, or an injury to the head. Further assessment and patient history should be reviewed to determine the cause of the client's symptom.
A client is admitted to the hospital with severe hypoparathyroidism. The nurse should do which of the following activities to promote client safety?
1. Keep the room slightly cool
2. Institute seizure precautions
3. Keep the head of bed lowered
4. Use a w
2. Institute seizure precautions
Rationale: Hypoparathyroidism results from insufficient parathyroid hormone, leading to low serum calcium levels. Hypocalcemia can cause tetany, which, if untreated can lead to seizures. The nurse should institute seizure precautions to maintain a safe environment. The other options do nothing to help this health problem or promote a safe environment for this client.
Hepatitis B: Boyfriend + test
Assess by asking if girlfriend has had unprotected sex with boyfriend
Transmitted by parenteral drug abuse and sexual contact
Determine exposure before implementing
Humulin NPH insulin is administered at 7am. At what time would the nurse anticipate the peak action to take place?
1. 9am
2. 12 noon
3. 5pm
4. 11pm
3. NPH is an intermediate-acting insulin. The peak action takes place 8-12 hours after administration. If NPH was given at 7am, the peak would occur between 3pm and 7pm.
Normal Value of PaCO2
35 to 45 mm Hg; measurement of CO2 pressure being exerted on plasma
What is the minimum time established for a health-care worker to properly wash the hands?
1. 10 seconds
2. 30 seconds
3. 45 seconds
4. 60 seconds
1. Proper handwashing by health-care workers reduces the risk of nosocomial infections. Ten seconds of vigorous handwashing will remove most transient flora and is the minimum amount of time one should spend washing.
To immobilize the surgical spine
A client with a cervical spine injury has Gardner-Wells tongs inserted for which of the following reasons?
According to the American Heart Association (AHA), which of the following is the most prevalent form of cardiovascular disease?
1. Stroke
2. Coronary Artery Disease (CAD)
3. Hypertension
4. Rheumatic heart disease
3. The AHA states the most prevalent form of cardivascular disease is hypertention, followed in descending order by CAD, rheumatic heart disease, and stroke.
To answer questions that ask for information regarding client care after leaving the hospital, always choose the answer that
includes rehabilitation planning and/or discharge planning. And remember, rehabilitation and discharge planning always
begin on th
Avoid selecting answers that use the words complete, total, and exclusively. These answers do not allow for the possibility of an exception.
A client who received a dose of chemotherapy 12 hours ago is incontinent of urine while in bed. The nurse safely wears which of the following when cleaning the client?
1. Mask and gloves
2. Gown and gloves
3. Mask, gown and gloves
4. Gown, gloves and eyew
2. Gown and gloves
Rationale: The client who has received chemotherapy will have antineoplastic agents or their metabolites in body fluids and excreta for 48 hours. For this reason, the nurse should wear protection for likely sources of contamination. In this instance, the nurse should wear gloves and a gown to protect the hands and uniform from contamination.
A nurse is assisting in preparing a plan of care for a client being admitted to the hospital for insertion of a cervical radiation implant. Which safe activity should the nurse suggest for this client following insertion of the implant?
1. Maintain bed re
1. Maintain bed rest
Rationale: The client with a cervical radiation implant should be maintained on bed rest in the dorsal position to prevent movement of the radiation source. The head of the bed is elevated to a maximum of 10 to 15 degrees for comfort. Turning the client on the side is avoided. If turning is absolutely necessary, a pillow is placed between the knees and, with the body in straight alignment the client is logrolled.
What is the normal Lithium value?
normal = < 1.5 mEq/L
toxic = > 2 mEq/L
A nurse who is assisting in the care of a client with cardiomyopathy should give priority to which of the following to ensure client safety>
1. Administering vasodilator medications
2. Conducting a thorough pain assessment
3. Taking measures to prevent or
3. Taking measures to prevent orthostatic changes when the client stands
Rationale: Orthostatic changes can occur in the client with cardiomyopathy as a result of impaired venous return. These changes could lead to dizziness and client falls. Vasodilators should not be administered. There is no mention of pain in the question, and pain may not directly affect safety in this event. Option 4 is an accurate statement but is not directly related to the subject of the question.
A nurse is assigned to care for a client with Parkinson's disease who has recently begun taking L-dopa (levodopa). Which of the following is most important to check before ambulating the client?
1. The client's history of falls
2. Assistive devices used b
3. The client's postural (orthostatic) vital signs
Rationale: Clients with Parkinson's disease are at risk for postural (orthostatic) hypotension from the disease. This problem worsens when L-dopa is introduced because the medication can also cause postural hypotension, thus increasing the client's risk for falls. Although knowledge of the client's use of assistive devices and history of falls is helpful, it is not the most important piece of data based on the information in this question. Clients with Parkinson's disease generally have resting rather then intention tremors.
What effect on a client's pulse rate would the LPV/LVN expect to occur from taking the medication propranolol (Inderal)?
Answer: The client's heart rate should be slower than it was prior to taking the medication.
Rationale: Propranolol (Inderal) is a beta-adrenergic blocker. "Beta blockers" interfere with the effects of the naturally occurring epinephrine in the body. These medications reduce the heart rate. Therefore, once the client has started taking propranolol (Inderal), the client's heart rate should slow down compared to the rate prior to taking the medication.
Does a weak base accept hydrogen ions less easily ?
Yes, a weak base does accept hydrogen ions less easily, but are extremely valuable in preventing major changes in the PH of extracellular fluid.
A client with a high cervical spine injury
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
A nurse is carrying out an order to obtain a sputum sample, which must be obtained using the saline inhalation method. The nurse guides the client in using the nebulizer safely and effectively by encouraging the client to do which of the following?
1. Hol
2. Keep the lips closed lightly over the mouthpiece
Rationale: Inhaling vaporized saline is an effective means to assist a client to cough productively because the vapor condenses on respiratory mucosa, stimulating the cough reflex and the expectoration of secretions. The nurse tells the client to hold gentle pressure between the lips and the mouthpiece. It is not necessary to form a tight seal. The client inhales vaporized saline with each breath until coughing results. The nebulizer is not held under the nose.
A nurse is assisting in the care of a client in labor who has a history of sickle cell anemia. Knowing that the client has a high risk for sickling crisis during labor, the nurse should give priority to implementing which safe nursing action to prevent a
3. Ensure that the client uses oxygen during labor
Rationale: Administering oxygen as needed is an effective intervention to prevent sickle cell crisis during labor. During the labor process the client is at high risk for being unable to meet the oxygen demands of labor and unable to prevent sickling. Option 1 is a safe nursing action, but it does nothing to prevent sickling crisis. Option 4 is not realistic and would not prevent sickling crisis. Option 2 is another generally helpful nursing measure but again is not related to prevention of sickling crisis.
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