Anemia

ANS: A All actions are appropriate, but remembering the ABCs, oxygen would come first. The main problem in a sickle cell crisis is tissue and organ hypoxia, so providing oxygen helps halt the process.

A client presents to the emergency department in sickle cell crisis. What intervention by the nurse takes priority? a. Administer oxygen. b. Apply an oximetry probe. c. Give pain medication. d. Start an IV line.

ANS: B Iron deficiency anemia is a type of microcytic, hypochromic anemia.

When obtaining assessment data from a patient with a microcytic, hypochromic anemia, you question the patient about a. folic acid intake. b. dietary intake of iron. c. a history of gastric surgery. d. a history of sickle cell anemia.

ANS: B Primary polycythemia often requires phlebotomy to reduce blood volume. The increased risk of thrombus formation that accompanies the disease requires regular exercises and ambulation. Deep-breathing and coughing exercises do not directly address the cause or common sequelae of polycythemia, and neurologic manifestations are not typical.

Caring for a patient with a diagnosis of polycythemia vera will likely require you to a. Encourage deep breathing and coughing. b. Assist with or perform phlebotomy at the bedside. c. Teach the patient how to maintain a low-activity lifestyle. d. Perform thorough and regularly scheduled neurologic assessments.

ANS: C Taking iron with vitamin C (ascorbic acid) or orange juice, which contains ascorbic acid, also enhances iron absorption. Milk may interfere with iron absorption. Ginger ale and water do not facilitate iron absorption.

When providing teaching for the patient with iron-deficiency anemia who has been prescribed iron supplements, you should include taking the iron with which beverage? a. Milk b. Ginger ale c. Orange juice d. Water

ANS: D As a result of repeated blood transfusions, excessive deposits of iron (hemosiderosis) are stored in tissues.

A child with thalassemia major receives blood transfusions frequently. The nurse is aware that a complication of repeated blood transfusions is: a. hemarthrosis. b. hematuria. c. hemoptysis. d. hemosiderosis.

ANS: A Because clients in sickle cell crisis are often dehydrated, the fluid of choice is a hypotonic solution such as 0.45% normal saline. 0.9% normal saline and lactated Ringer's solution are isotonic. D50 is hypertonic and not used for hydration.

A client in sickle cell crisis is dehydrated and in the emergency department. The nurse plans to start an IV. Which fluid choice is best? a. 0.45% normal saline b. 0.9% normal saline c. Dextrose 50% (D50) d. Lactated Ringer's solution

ANS: A Thrombosis is the most likely complication. The patient with polycythemia may experience angina, heart failure, intermittent claudication, and thrombophlebitis, which may be complicated by embolization. The most common and serious acute complication is stroke due to thrombosis.

A complication of the hyperviscosity of polycythemia is a. Thrombosis. b. Cardiomyopathy. c. Pulmonary edema. d. Disseminated intravascular coagulation (DIC).

ANS: B The children of the client with sickle cell disease will inherit the sickle cell trait, but may not inherit the disease. If both parents have the sickle cell trait, their children could get the disease.

The nurse is reinforcing information about genetic counseling to a client with sickle cell disease who has a healthy spouse. What information does the nurse include? a. "Sickle cell disease will be inherited by your children." b. "The sickle cell trait will be inherited by your children." c. "Your children will have the disease, but your grandchildren will not." d. "Your children will not have the disease, but your grandchildren could."

ANS: D An adequate dosage of iron turns the stools a tarry green color.

The parent of a child receiving an iron preparation tells the nurse that the child's stools are a tarry green color. The nurse should explain that this is a/an: a. Symptom of iron-deficiency anemia. b. Adverse effect of the iron preparation. c. Indicator of an iron preparation overdose. d. Normally expected change caused by the iron preparation.

ANS: A The cause of sickle cell anemia involves increased hemolysis. Thalassemias and folic acid deficiencies decrease erythropoiesis, whereas the anemia related to menstruation is a direct result of blood loss.

Which patient is most likely to experience anemia caused by increased destruction of RBCs? a. An African American man who has a diagnosis of sickle cell disease b. A 59-year-old man whose alcoholism has precipitated folic acid deficiency c. A 30-year-old woman with a history of "heavy periods" accompanied by anemia d. A 3-year-old child whose impaired growth and development is attributable to thalassemia

ANS: A Because all marrow elements are affected, hemoglobin, WBC, and platelet values are decreased in aplastic anemia. Other RBC indices usually are normal.

You are evaluating the laboratory data of the patient with suspected aplastic anemia. Which findings support this diagnosis? a. Reduced RBCs, reduced white blood cells (WBCs), and reduced platelets b. Reduced RBCs, normal WBCs, and normal platelets c. Normal RBCs, reduced WBCs, and reduced platelets d. Elevated RBCs, increased WBCs, and increased platelets

ANS: A Regardless of how much cobalamin (B12) is ingested, the patient is not able to absorb it if intrinsic factor is lacking or if there is impaired absorption in the ileum. For this reason, increasing dietary cobalamin does not correct the anemia. However, the patient should be instructed about adequate dietary intake to maintain good nutrition. Parenteral or intranasal administration of cobalamin is the treatment of choice. Without cobalamin administration, these individuals will die in 1 to 3 years.

You encourage the patient with cobalamin (B12) deficiency to seek treatment because untreated pernicious anemia may result in a. Death. b. Liver failure. c. Heart failure. d. Gastrectomy.

ANS: B The client needs IV pain relief, and it should be administered on a routine schedule (i.e., before the client has to request it). Morphine is not administered intramuscularly (IM) to clients with sickle cell disease (SCD). In fact, all IM injections are avoided because absorption is impaired by poor perfusion and sclerosed skin. Nonsteroidal anti-inflammatory drugs may be used for clients with SCD for pain relief once their pain is under control; however, in a crisis, this choice of analgesic is not strong enough. Moderate pain may be treated with oral opioids, but this client is in a sickle cell crisis; IV analgesics should be used until his or her condition stabilizes.

A recently admitted client who is in sickle cell crisis requests "something for pain." What does the nurse administer? a. IM morphine sulfate b. IV hydromorphone (Dilaudid) c. Oral ibuprofen (Motrin) d. Oral morphine sulfate (MS-Contin)

ANS: A Because cow's milk contains very little iron, infants should drink iron-fortified formula for the first year of life.

2. The statement by a mother that may indicate a cause for her 9-month-old having iron deficiency anemia is: a. "Formula is so expensive. We switched to regular milk right away." b. "She almost never drinks water." c. "She doesn't really like peaches or pears, so we stick to bananas for fruit." d. "I give her a piece of bread now and then. She likes to chew on it."

ANS: A An elevated creatinine indicates kidney damage, which occurs in SCD. A hematocrit level of 30% is an expected finding, as is a slightly elevated white blood cell count. A sodium level of 147 mEq/L, although slightly high, is not concerning.

A nurse caring for a client with sickle cell disease (SCD) reviews the client's laboratory work. Which finding should the nurse report to the provider? a. Creatinine: 2.9 mg/dL b. Hematocrit: 30% c. Sodium: 147 mEq/L d. White blood cell count: 12,000/mm3

ANS: C The manifestations, including growth and developmental deficits, develop in childhood by 2 years of age.

You anticipate the onset of manifestations related to thalessemia to occur by a. 6 months of age. b. age 1 year. c. age 2 year. d. adolescence.

ANS: D, E, F In an older adult receiving a transfusion, hypertension is a sign of overload, low blood pressure is a sign of a transfusion reaction, and a rapid and bounding pulse is a sign of fluid overload. In this scenario, 2 units, or about a liter of fluid, could be problematic. Capillary refill time that is less than 3 seconds is considered to be normal and would not pose a problem. Increased (not decreased) pallor and cyanosis are signs of a transfusion reaction, while swollen (not flattened) superficial veins are present in fluid overload in older adult clients receiving transfusions.

An 82-year-old client with anemia is requested to receive 2 units of whole blood. Which assessment findings cause the nurse to discontinue the transfusion because it is unsafe for the client? (Select all that apply.) a. Capillary refill less than 3 seconds b. Decreased pallor c. Flattened superficial veins d. Hypertension e. Hypotension f. Rapid, bounding pulse

ANS: A Patients with severe anemia (hemoglobin <6 g/dL) exhibit the following cardiovascular and pulmonary manifestations: tachycardia, increased pulse pressure, systolic murmurs, intermittent claudication, angina, heart failure, myocardial infarction; tachypnea, orthopnea, dyspnea at rest.

In a severely anemic patient, you expect to find a. dyspnea and tachycardia. b. cyanosis and pulmonary edema. c. cardiomegaly and pulmonary fibrosis. d. ventricular dysrhythmias and wheezing.

ANS: C As a result of accelerated RBC breakdown, the patient may have characteristic clinical findings of hemolysis, including jaundice and elevated serum bilirubin levels.

In addition to altered red blood cells (RBCs), which laboratory finding does the nurse expect for the patient with sickle cell disease? a. Leukocytosis b. Hypouricemia c. Hyperbilirubinemia d. Hypercholesteremia

ANS: B Pain is the most common clinical manifestation of a crisis and usually requires large doses of continuous opioids for control. Fluid intake should be increased to reduce blood viscosity and improve perfusion. Rest is usually ordered to decrease metabolic requirements. Patients are instructed about the need for dietary folic acid, but high-protein, high-calorie diets are not emphasized.

It is important for the nurse providing care for a patient with sickle cell crisis to a. limit the patient's intake of oral and IV fluids. b. evaluate the effectiveness of opioid analgesics. c. encourage the patient to ambulate as much as tolerated. d. teach the patient about high-protein, high-calorie foods.

ANS: D Jaundice is likely because the increased destruction of RBCs causes an elevation in bilirubin levels. The spleen and liver may enlarge because of their hyperactivity, which is related to macrophage phagocytosis of the defective erythrocytes. The other symptoms are common to all types of anemia.

Which sign or symptom would you recognize as a unique characteristic specific to hemolytic anemia? a. Tachycardia b. Weakness c. Decreased RBCs d. Jaundice

ANS: A & B The stool guaiac test is done to determine whetherthe cause of the iron-deficiency anemia is related to gastrointestinal bleeding. Iron should be increased in the diet. Teach the patient which foods are good sources of iron. If nutrition is already adequate, increasing iron intake by dietary means may not be practical. The patient with iron deficiency related to acute blood loss may require a transfusion of packed red blood cells (RBCs).

Nursing interventions for a patient with severe anemia related to peptic ulcer disease include (select all that apply) a. Monitoring stools for guaiac. b. Instructions about a high-iron diet. c. Taking vital signs every 8 hours. d. Teaching self-injection of erythropoietin.

ANS: A & B Anemia of chronic disease, also called anemia of inflammation, is associated with an underproduction of RBCs and mild shortening of RBC survival. The RBCs are usually normocytic, normochromic, and hypoproliferative. The anemia is usually mild, but it can be more severe.

You correctly identify which descriptions as characteristic of anemia of chronic disease (select all that apply) a. Normocytic. b. Normochromic. c. Microcytic. d. Hypochromic. e. Proliferative.

ANS: C Vaso-occlusive crisis, or painful crisis, is caused by obstruction of blood flow by sickle cells, infarctions, and some degrees of vasospasm.

A 3-year-old child with sickle cell disease is admitted to the hospital in sickle cell crisis with severe abdominal pain. The nurse recognizes that the type of crisis the child is most likely experiencing is: a. aplastic. b. hyperhemolytic. c. vaso-occlusive. d. splenic sequestration.

ANS: B Hydroxyurea (Droxia) has been used successfully to reduce sickling of cells and pain episodes associated with sickle cell disease (SCD). Clients with SCD are not prescribed anticoagulants such as heparin or warfarin (Coumadin). t-PA is used as a "clot buster" in clients who have had ischemic strokes.

A 32-year-old client is recovering from a sickle cell crisis. His discomfort is controlled with pain medications and he is to be discharged. What medication does the nurse expect to be prescribed for him before his discharge? a. Heparin (Heparin) b. Hydroxyurea (Droxia) c. Tissue plasminogen activator (t-PA) d. Warfarin (Coumadin)

ANS: C Prophylactic therapy with twice-daily oral penicillin reduces the incidence of pneumonia and other streptococcal infections and is the correct drug to use. It is a standard protocol for long-term prophylactic use in clients with sickle cell disease. Cefaclor (Ceclor) and vancomycin (Vancocin) are antibiotics more specific for short-term use and would be inappropriate for this client. Gentamicin (Garamycin) is a drug that can cause liver and kidney damage with long-term use.

A 32-year-old client recovering from a sickle cell crisis is to be discharged. The nurse says, "You and all clients with sickle cell disease are at risk for infection because of your decreased spleen function. For this reason, you will most likely be prescribed an antibiotic before discharge." Which drug does the nurse anticipate the health care provider will request? a. Cefaclor (Ceclor) b. Gentamicin (Garamycin) c. Penicillin V (Pen-V K) d. Vancomycin (Vancocin)

ANS: B Hypoxia and deoxygenation of the RBCs are the most common cause of sickling, so administration of oxygen is the priority intervention here. Pain control and hydration are also important interventions for this patient and should be accomplished rapidly. Vaccination may help prevent future sickling episodes by decreasing the risk of infection, but it will not help with the current sickling crisis. Focus: Prioritization

A 32-year-old patient with sickle cell anemia is admitted to the hospital during a sickle cell crisis. Which action prescribed by the health care provider will you implement first? a. Give morphine sulfate 4 to 8 mg IV every hour as needed. b. Administer 100% oxygen using a nonrebreather mask. c. Start a 14-gauge IV line and infuse normal saline at 200 mL/hr. d. Give pneumococcal (Pneumovax) and Haemophilus influenzae (ActHIB) vaccines.

ANS: C Because pernicious anemia prevents the absorption of vitamin B12, this patient requires injections or intranasal administration of cobalamin. Alcohol use does not cause cobalamin deficiency. Proton pump inhibitors decrease the absorption of vitamin B12. Eating more foods rich in vitamin B12 is not helpful because the lack of intrinsic factor prevents absorption of the vitamin.

A 52-year-old patient has a new diagnosis of pernicious anemia. The nurse determines that the patient understands the teaching about the disorder when the patient states, "I a. need to start eating more red meat and liver." b. will stop having a glass of wine with dinner." c. could choose nasal spray rather than injections of vitamin B12." d. will need to take a proton pump inhibitor like omeprazole (Prilosec)."

ANS: D The patient's clinical manifestations indicate moderate anemia, which is consistent with a Hgb of 6 to 10 g/dL. The other values are all within the range of normal.

A 62-year old man with chronic anemia is experiencing increased fatigue and occasional palpitations at rest. The nurse would expect the patient's laboratory findings to include a. a hematocrit (Hct) of 38%. b. an RBC count of 4,500,000/μL. c. normal red blood cell (RBC) indices. d. a hemoglobin (Hgb) of 8.6 g/dL (86 g/L).

ANS: D Sickle cell disease is an autosomal recessive disorder; therefore both parents must have the trait for the child to have the disease.

A child is diagnosed with sickle cell disease. The parents are unsure of how their child contracted the disease. What is the most appropriate explanation by the nurse? a. The mother has the trait, but the father does not. b. The father has the trait, but the mother does not. c. The mother has the disease, but the father has neither the trait nor the disease. d. The mother and father have the trait; therefore the child has a 25% chance for having the disease.

ANS: B-C-E Children should have a diet high in calcium or be placed on calcium supplements to reduce the risk of osteopenia. Live plants and fresh vegetables should be avoided because they carry bacteria. Practicing good hand hygiene is essential to prevent the spread of infection .Children cannot return to school for 6-12 months after HSCT. Either in-hospital or home schooling is required. Children and their families should be encouraged to get yearly influenza vaccination.

A child is status post hematopoietic stem cell transplantation (HSCT) and is preparing for discharge home. Based on the nurse's knowledge of HSCT, which concepts are important to include in the discharge teaching plan of care? (Select all that apply.) a. Preparing the child to return to school within six weeks b. Keeping the child on a high-calcium diet c. Avoiding live plants and fresh vegetables d. Avoiding influenza vaccinations e. Practicing good hygiene

ANS: C Severe chest pain, fever, a cough, and dyspnea are the signs and symptoms of chest syndrome. The nurse must notify the practitioner immediately. Breathing 100% oxygen to relieve hypoxia may be ordered by the practitioner, but the first action is notification because these symptoms indicate a medical emergency. Pain medications may be indicated, but evaluation is necessary first. Severe chest pain, fever, cough, and dyspnea are not signs of a stroke.

A child with sickle cell anemia develops severe chest pain, fever, a cough, and dyspnea. The nurse's first action is to a. Administer 100% oxygen to relieve hypoxia. b. Administer pain medication to relieve symptoms. c. Notify practitioner because chest syndrome is suspected. d. Notify practitioner because child may be having a stroke.

ANS: D A side effect of hypertransfusion therapy is often iron overload. Deferoxamine is an iron-chelating drug that binds excess iron; therefore, it can be excreted by the kidneys. Deferoxamine does not prevent blood transfusions. Deferoxamine does not stimulate red cell production. Deferoxamine is not a vitamin supplement.

A child with β-thalassemia is receiving numerous blood transfusions. In addition, the child is receiving deferoxamine (Desferal) therapy. The child's parents ask the nurse what deferoxamine does. The most appropriate response by the nurse is a. "The medication helps to prevent blood transfusion reactions." b. "The medication stimulates red blood cell production." c. "The medication provides vitamin supplementation." d. "The medication helps to prevent iron overload."

ANS: B The best response is for the nurse to offer self, a therapeutic communication technique that uses presence. Attempting to assign blame to both parents will not help the client feel better. There is genetic testing available, so it is inaccurate to state there is no way to know who will have the disease. Stating that good treatments exist belittles the client's feelings.

A client admitted for sickle cell crisis is distraught after learning her child also has the disease. What response by the nurse is best? a. "Both you and the father are equally responsible for passing it on." b. "I can see you are upset. I can stay here with you a while if you like." c. "It's not your fault; there is no way to know who will have this disease." d. "There are many good treatments for sickle cell disease these days."

ANS: A Malabsorption syndromes such as Crohn's disease leave a client prone to folic acid deficiency. Fanconi's anemia, hemolytic anemia, and vitamin B12 anemia are not related to Crohn's disease.

A client has Crohn's disease. What type of anemia is this client most at risk for developing? a. Folic acid deficiency b. Fanconi's anemia c. Hemolytic anemia d. Vitamin B12 anemia

ANS: B This client has laboratory findings indicative of iron deficiency anemia. The most common cause of this disorder is blood loss, often from the GI tract. The nurse should perform a Hemoccult test on the client's stools. High-protein foods may help the condition, but dietary interventions take time to work. That still does not determine the cause. Frequent oral care is not related. Cobalamin injections are for pernicious anemia.

A client has a serum ferritin level of 8 ng/mL and microcytic red blood cells. What action by the nurse is best? a. Encourage high-protein foods. b. Perform a Hemoccult test on the client's stools. c. Offer frequent oral care. d. Prepare to administer cobalamin (vitamin B12).

ANS: C During a sickle cell crisis, the tissue distal to the occlusion has decreased blood flow and ischemia, leading to pain. Due to decreased blood flow, the client's legs will be cool or cold. The UAP can attempt to keep the client's legs warm. Ice and elevation will further decrease perfusion. Elastic bandage wraps are not indicated and may constrict perfusion in the legs.

A client has a sickle cell crisis with extreme lower extremity pain. What comfort measure does the nurse delegate to the unlicensed assistive personnel (UAP)? a. Apply ice packs to the client's legs. b. Elevate the client's legs on pillows. c. Keep the lower extremities warm. d. Place elastic bandage wraps on the client's legs.

ANS: A Clients with sickle cell crisis often have severe pain that is managed with up to 48 hours of IV opioid analgesics. Even if the client is addicted and drug seeking, he or she is still in extreme pain. If the client can receive another dose of medication, the nurse should provide it. The other options are judgmental and do not address the client's pain. Giving placebos is unethical.

A client hospitalized with sickle cell crisis frequently asks for opioid pain medications, often shortly after receiving a dose. The nurses on the unit believe the client is drug seeking. When the client requests pain medication, what action by the nurse is best? a. Give the client pain medication if it is time for another dose. b. Instruct the client not to request pain medication too early. c. Request the provider leave a prescription for a placebo. d. Tell the client it is too early to have more pain medication.

ANS: D Although individuals with SCD often have elevated white blood cell (WBC) counts, this extreme elevation could indicate leukemia, a complication of taking hydroxyurea. The nurse should report this finding immediately. Alternatively, it could indicate infection, a serious problem for clients with SCD. Hematocrit and hemoglobin levels are normally low in people with SCD. The potassium level, while slightly low, is not as worrisome as the WBCs.

A client with sickle cell disease (SCD) takes hydroxyurea (Droxia). The client presents to the clinic reporting an increase in fatigue. What laboratory result should the nurse report immediately? a. Hematocrit: 25% b. Hemoglobin: 9.2 mg/dL c. Potassium: 3.2 mEq/L d. White blood cell count: 38,000/mm3

ANS: D Monitoring hydration status is important during an acute exacerbation because the patient is at risk for fluid overload or underhydration. Aspirin therapy is used to decrease risk for thrombosis. The patient should be encouraged to ambulate to prevent deep vein thrombosis (DVT). Iron is contraindicated in patients with polycythemia vera.

A critical action by the nurse caring for a patient with an acute exacerbation of polycythemia vera is to a. place the patient on bed rest. b. administer iron supplements. c. avoid use of aspirin products. d. monitor fluid intake and output.

ANS: C The sickle cell gene is inherited from both parents; therefore each offspring has a one in four chance of inheriting the disease.

A newly married couple is seeking genetic counseling because they are both carriers of the sickle cell trait. How can the nurse best explain the children's risk of inheriting this disease? a. Every fourth child will have the disease; two others will be carriers. b. All of their children will be carriers, just as they are. c. Each child has a one in four chance of having the disease and a two in four chance of being a carrier. d. The risk levels of their children cannot be determined by this information.

ANS: B Clients with polycythemia vera often have clotting abnormalities due to the hyperviscous blood with sluggish flow. The client reporting shortness of breath may have a pulmonary embolism and should be seen first. The client with a swollen calf may have a deep vein thrombosis and should be seen next. High blood pressure and gout symptoms are common findings with this disorder.

A nurse in a hematology clinic is working with four clients who have polycythemia vera. Which client should the nurse see first? a. Client with a blood pressure of 180/98 mm Hg b. Client who reports shortness of breath c. Client who reports calf tenderness and swelling d. Client with a swollen and painful left great toe

ANS: A, C, D, E Several factors cause red blood cells to sickle in SCD, including dehydration, extreme stress, high altitudes, and pregnancy. Strenuous exercise can also cause sickling, but not unless it is very vigorous.

A nurse working with clients with sickle cell disease (SCD) teaches about self-management to prevent exacerbations and sickle cell crises. What factors should clients be taught to avoid? (Select all that apply.) a. Dehydration b. Exercise c. Extreme stress d. High altitudes e. Pregnancy

ANS: B Methotrexate use can lead to folic acid deficiency. Supplementation with oral folic acid supplements is the usual treatment. The other nutrients would not correct folic acid deficiency, although they would be used to treat other types of anemia.

A patient who is receiving methotrexate for severe rheumatoid arthritis develops a megaloblastic anemia. The nurse will anticipate teaching the patient about increasing oral intake of a. iron. b. folic acid. c. cobalamin (vitamin B12). d. ascorbic acid (vitamin C).

ANS: A Because sickle cell disease is commonly diagnosed during childhood, the pediatric nurse will be familiar with the disease and with red blood cell transfusion; therefore, he or she should be assigned to the client with sickle cell disease. Aplastic anemia, folic acid deficiency, and polycythemia vera are problems more commonly seen in adult clients who should be cared for by nurses who are more experienced in caring for adults.

An RN from pediatrics has "floated" to the medical-surgical unit. Which client is assigned to the float nurse? a. A 42-year-old with sickle cell disease receiving a transfusion of red blood cells b. A 50-year-old with pancytopenia needing assessment of risk factors for aplastic anemia c. A 55-year-old with folic acid deficiency anemia caused by alcohol abuse who needs counseling d. A 60-year-year with newly diagnosed polycythemia vera who needs teaching about the disease

ANS: B Nursing care for patients with anemia should alternate periods of rest and activity to encourage activity without causing undue fatigue. There is no indication that the patient has a bleeding disorder, so a diet high in vitamin K or teaching about how to avoid injury is not needed. Protective isolation might be used for a patient with aplastic anemia, but it is not indicated for hemolytic anemia.

An appropriate nursing intervention for a hospitalized patient with severe hemolytic anemia is to a. provide a diet high in vitamin K. b. alternate periods of rest and activity. c. teach the patient how to avoid injury. d. place the patient on protective isolation.

ANS: B Thalassemia is a group of autosomal recessive diseases that involve inadequate production of normal hemoglobin. Hemolysis also occurs in thalassemia, but insufficient production of normal hemoglobin is the predominant problem. Erythropoietin deficiency is associated with a renal disorder, and S-shaped hemoglobin is associated with sickle cell disease.

The primary pathophysiology underlying thalassemia is a. erythropoietin deficiency. b. abnormal hemoglobin synthesis. c. autoimmunity. d. S-shaped hemoglobin.

ANS: A Parietal cell function can be assssed with a Schilling test. After radioactive B12 is administered to the patient, the amount of cobalamin excreted in the urine is measured. An individual who cannot absorb cobalamin excretes only a small amount of this radioactive form.

The Schilling test for pernicious anemia involves a. Administration of radioactive B12 and measuring its excretion in the urine. b. Blood cultures for organism identification. c. The measurement of serum iron. d. The administration of iron and blood assessment of total iron binding in 24 hours.

ANS: D You must assist the patient in reducing infection risk. The patient is susceptible to infection and is at risk for septic shock and death. Even a low-grade temperature (>100.4° F) should be considered a medical emergency. Thrombocytopenia manifests as a predisposition to bleeding evidenced by petechiae, ecchymosis, and epistaxis. Pain is not experienced nor is diarrhea. Nausea and malnutrition are not related to this disease except as a by-product of infection.

The care plan for a patient with aplastic anemia should include activities to minimize the risk for which complications? a. Dyspnea and pain b. Diarrhea and fatigue c. Nausea and malnutrition d. Infection and hemorrhage

ANS: B Because the patient with aplastic anemia has pancytopenia, the patient is at risk for infection and bleeding. There is no increased risk for seizures, neurogenic shock, or pulmonary edema.

Which collaborative problem will the nurse include in a care plan for a patient admitted to the hospital with idiopathic aplastic anemia? a. Potential complication: seizures b. Potential complication: infection c. Potential complication: neurogenic shock d. Potential complication: pulmonary edema

ANS: D This condition is known as glossitis, and is characteristic of B12 anemia. If the anemia is a pernicious anemia, it is treated with cobalamin. Genetic testing is not a priority for this condition. The client does not need high-fiber foods or protective precautions.

The nurse assesses a client's oral cavity and finds the tongue to be swollen with a smooth appearance. What action by the nurse is most appropriate? a. Encourage the client to have genetic testing. b. Instruct the client on high-fiber foods. c. Place the client in protective precautions. d. Teach the client about cobalamin therapy.

ANS: A The low white blood cell count indicates that the patient is at high risk for infection and needs immediate actions to diagnose and treat the cause of the leucopenia. The other information may require further assessment or treatment, but does not place the patient at immediate risk for complications.

The nurse has obtained the health history, physical assessment data, and laboratory results shown in the accompanying figure for a patient admitted with aplastic anemia. Which information is most important to communicate to the health care provider? a. Neutropenia b. Increasing fatigue c. Thrombocytopenia d. Frequent constipation

ANS: D Analgesics are needed to treat sickle cell pain. Warm soaks or compresses can help reduce pain perception. Cool compresses do not help the client in sickle cell crisis. Birth control is not the priority for this client. Increasing iron in the diet is not pertinent for the client in sickle cell crisis.

The nurse is caring for a client who is in sickle cell crisis. What action does the nurse perform first? a. Apply cool compresses to the client's forehead b. Encourage the client's use of two methods of birth control c. Increase food sources of iron in the client's diet d. Provide pain medications as needed.

ANS: B Prevention and early detection strategies are used to protect the client in sickle cell crisis from infection. Frequent and thorough handwashing is of the utmost importance. Drug therapy is a major defense against infections that develop in the client with sickle cell disease, but is not the most effective way that the nurse can reduce the potential for sepsis. Continually assessing the client for infection and monitoring the daily complete blood count with differential white blood cell count is early detection, not prevention. Taking vital signs every 4 hours will help with early detection of infection, but is not prevention.

The nurse is caring for a client with sickle cell disease. Which action is most effective in reducing the potential for sepsis in this client? a. Administering prophylactic drug therapy b. Frequent and thorough handwashing c. Monitoring laboratory values to look for abnormalities d. Taking vital signs every 4 hours, day and night

ANS: B The client with SCD should receive annual influenza and pneumonia vaccinations; this helps prevent the development of these infections, which could cause a sickle cell crisis. Handwashing is a very important habit for the client with SCD to develop because it reduces the risk for infection. Prophylactic penicillin is given to clients with SCD orally twice a day to prevent the development of infection.

The nurse is educating a group of young women who have sickle cell disease (SCD). Which comment from a class member requires correction? a. "Frequent handwashing is an important habit for me to develop." b. "Getting an annual 'flu shot' would be dangerous for me." c. "I must take my penicillin pills as prescribed, all the time." d. "The pneumonia vaccine is protection that I need."

ANS: A, B, D, F It is critical to have others help the anemic client who is extremely tired. Although it may be difficult for him or her to ask for help, this practice should be stressed to the client. Drinking small protein or nutritional supplements will help rebuild the client's nutritional status. Having four to six small meals daily is preferred over three large meals; this practice conserves the body's expenditure of energy used in digestion and assimilation of nutrients. Stopping activities when strain on the cardiac or respiratory system is noted is critical. A complete bath should be performed only every other day; on days in between, the client can be taught to take a "mini" sponge bath, which will conserve energy and still be safe in preventing the risks for infection. Care activities should be spaced every hour or so rather than in groups to conserve energy; the time just before and after meals should be avoided.

The nurse is teaching a client with newly diagnosed anemia about conserving energy. What does the nurse tell the client? (Select all that apply.) a. "Allow others to perform your car during periods of extreme fatigue." b. "Drink small quantities of protein shakes and nutritional supplements daily." c. "Perform a complete bath daily to reduce your chance of getting an infection." d. "Provide yourself with four to six small, easy-to-eat meals daily." e. "Perform your care activities in groups to conserve your energy." f. "Stop activity when shortness of breath or palpitations are present."

ANS: A Dairy products such as milk, cheese, and eggs will provide the vitamin B12 that the client needs. Grains, leafy vegetables, and starchy vegetables are not a source of vitamin B12.

The nurse is teaching a client with vitamin B12 deficiency anemia about dietary intake. Which type of food does the nurse encourage the client to eat? a. Dairy products b. Grains c. Leafy vegetables d. Starchy vegetables

ANS: B Jaundice is caused by the elevation of bilirubin level associated with red blood cell (RBC) hemolysis. The other tests would not be helpful in monitoring or treating a hemolytic anemia.

The nurse notes scleral jaundice in a patient being admitted with hemolytic anemia. The nurse will plan to check the laboratory results for the a. Schilling test. b. bilirubin level. c. stool occult blood test. d. gastric analysis testing.

ANS: B Vitamin C aids in the absorption of iron, whereas food and milk interfere with the absorption of iron.

The nurse would instruct the parent to give ferrous sulfate drops to the child: a. with milk. b. with orange juice. c. with water. d. on a full stomach.

ANS: A, B, C, & D The CBC count is monitored. Infections are common with an elevated white blood cell (WBC) count, and anemia may occur with low hemoglobin and red blood cell (RBC) levels. Oxygen may be administered to treat hypoxia and control sickling. Rest may be instituted to reduce metabolic requirements and deep vein thrombosis prophylaxis (using anticoagulants) prescribed. Transfusion therapy is indicated when an aplastic crisis occurs. Patients may require iron chelation therapy to reduce transfusion-produced iron overload. Pain occurring during an acute crisis usually is undertreated. Patients should have optimal pain control with opioid analgesics, nonsteroidal antiinflammatory agents, antineuropathic pain medications, local anesthetics, or nerve blocks.

The nursing management of a patient in sickle cell crisis includes (select all that apply) a. monitoring of the complete blood cell (CBC) count. b. blood transfusions if required and iron chelation. c. optimal pain management and oxygen therapy. d. rest as needed and deep vein thrombosis prophylaxis.

ANS: C SCA is inherited as an autosomal recessive disorder. In this inheritance pattern, there is a 25% chance that each subsequent child will have the disorder. SCA is an inherited hemoglobinopathy. In autosomal recessive disorders, there is a chance that 25% of the children will not have either SCA or sickle cell trait. There is a chance that 50% of the siblings will have sickle cell trait.

The parents of a child with sickle cell anemia (SCA) are concerned about subsequent children having the disease. Which response by the nurse is most accurate? a. "SCA is not inherited." b. "All siblings will have SCA." c. "There is a 25% chance of a sibling having SCA." d. "There is a 50% chance of a sibling having SCA."

ANS: B Prevention of dehydration, which can trigger the sickling process, is a priority goal in the care of a child with sickle cell disease.

The statement made by a parent indicating understanding of health maintenance of a child with sickle cell disease is: a. "I should give my child a daily iron supplement." b. "It is important for my child to drink plenty of fluids." c. "He needs to wear protective equipment if he plays contact sports." d. "He shouldn't receive any immunizations until he is older."

ANS: A An experienced UAP will have been taught how to obtain a stool specimen for the Hemoccult slide test, because this is a common screening test for hospitalized patients. Having the patient sign an informed consent form should be done by the physician who will be performing the colonoscopy. Administering medications and checking for allergies are within the scope of practice of licensed nursing staff. Focus: Delegation

These activities are included in the care plan for a 78-year-old patient admitted to the hospital with anemia caused by possible gastrointestinal bleeding. Which activity can you delegate to an experienced UAP? a. Obtaining stool specimens for fecal blood test (Hemoccult) slides b. Having the patient sign a colonoscopy consent form c. Giving the prescribed polyethylene glycol electrolyte solution (GoLYTELY) d. Checking for allergies to contrast dye or shellfish

ANS: A, B, C, D, E All of the options are classic signs of thalassemia major.

What are the classic symptoms of thalassemia major (Cooley's anemia)? Select all that apply. a. Hepatomegaly b. Jaundice c. Protruding teeth d. Pathological fractures e. Cardiac failure

ANS: B, D, E, F Difficulty breathing—especially with activity—is common with anemia. Lower levels of hemoglobin carry less O2 to the cells of the body. Fatigue is a classic symptom of anemia; lowered O2 levels contribute to a faster pulse (i.e., cardiac rate) and tend to "wear out" a client's energy. Lowered O2 levels deliver less oxygen to all cells, making clients with anemia pale—especially their ears, nail beds, palms, and conjunctivae and around the mouth. Respiratory problems with anemia do not include changes in breath sounds; dyspnea and decreased oxygen saturation levels are present. Skin is cool to the touch, and an intolerance to cold is noted; elevated temperature would signify something additional, such as infection.

What are the typical clinical manifestations of anemia? a. Decreased breath sounds B. Dyspnea on exertion c. Elevated temperature d. Fatigue e. Pallor f. Tachycardia

ANS: A Children and their families need specific instructions on how to minimize crises, including preventing infections; maintaining adequate hydration; and addressing environmental concerns, such as avoidance of extreme cold. Genetic counseling is important, but teaching care for the child is a priority. Sickle cell anemia is a long-term, chronic illness. Multiple blood transfusions are an option for some children with sickle cell disease. The priority is that the child and the parents are properly prepared to manage the chronic disease.

What is the most important nursing consideration when caring for a child with sickle cell anemia? a. Teach the parents and child how to minimize crises. b. Refer the parents and child for genetic counseling. c. Help the child and family to adjust to a short-term disease. d. Observe for complications of multiple blood transfusions.

Answer: B Rationale: The patient with a low hemoglobin level and hematocrit is anemic and is most likely to experience fatigue. Fatigue develops because of the lowered oxygen-carrying capacity that leads to reduced tissue oxygenation with which to carry out cellular functions.

When caring for a patient with metastatic cancer, you note a hemoglobin level of 8.7 g/dL and hematocrit of 26%. You place highest priority on initiating interventions that can reduce A. thirst. B. fatigue. C. headache. D. abdominal pain.

ANS: B Good nutritional sources of iron include boiled egg yolk, liver, green leafy vegetables, cream of Wheat, dried fruits, beans, nuts, and whole-grain breads.

When teaching the parents of a young child about iron deficiency anemia, the nurse would tell them that a rich source of iron is: a. an egg white. b. cream of Wheat. c. a banana. d. a carrot.

ANS: C The frequent transfusions used to treat thalassemia major lead to iron toxicity in patients unless iron chelation therapy is consistently used. Iron supplementation is avoided in patients with thalassemia. There is no need to avoid intramuscular injections. The goal for patients with thalassemia major is to maintain a hemoglobin of 10 g/dL or greater.

Which action will the nurse include in the plan of care for a patient who has thalassemia major? a. Teach the patient to use iron supplements. b. Avoid the use of intramuscular injections. c. Administer iron chelation therapy as needed. d. Notify health care provider of hemoglobin 11g/dL.

ANS: B Because clients with aplastic anemia usually have low white blood cell counts that place them at high risk for infection, roommates such as the client with G6PD deficiency anemia should be free from infection or infection risk. The client with sickle cell disease has two draining leg ulcer infections that would threaten the diminished immune system of the client with aplastic anemia. The client with leukemia who is receiving induction chemotherapy and the client with idiopathic thrombocytopenia who is taking steroids are at risk for development of infection, which places the client with aplastic anemia at risk, too.

Which client does the nurse assign as a roommate for the client with aplastic anemia? a. a 23-year-old with sickle cell disease who has two draining leg ulcers b. A 28-year-old with glucose-6-phosphate dehydrogenase (G6PD) deficiency anemia who is receiving mannitol (Osmitrol) c. A 30-year-old with leukemia who is receiving induction chemotherapy d. A 34-year-old with idiopathic thrombocytopenia who is taking steroids

ANS: B Stem cell transplantation in the home setting requires support, assistance, and coordination from others. The client cannot manage this type of care on his own. The client must be emotionally stable to be a candidate for this type of care. It is acceptable for the client's spouse to support the client undergoing this procedure. It is not unexpected for the client to be taking several prescriptions. Five miles is an acceptable distance from the hospital, in case of emergency.

Which client statement indicates that stem cell transplantation that is scheduled to take place in his home is not a viable option? a. "I don't feel strong enough, but my wife said she would help." b. "I was a nurse, so I can take care of myself." c. "I will have lots of medicine to take." d. "We live 5 miles from the hospital."

ANS: C The calf swelling and pain suggest that the patient may have developed a deep vein thrombosis, which will require diagnosis and treatment to avoid complications such as pulmonary embolus. The other findings will also be reported to the health care provider but are expected in a patient with this diagnosis.

Which finding about a patient with polycythemia vera is most important for the nurse to report to the health care provider? a. Hematocrit 55% b. Presence of plethora c. Calf swelling and pain d. Platelet count 450,000/μL

ANS: B The absence of neurologic problems is an important diagnostic finding and differentiates folic acid deficiency from cobalamin deficiency.

Which finding allows you to identify the patient's anemia as folic acid deficiency rather than B12 deficiency? a. Loss of appetite b. Lack of neuromuscular symptoms c. Red tongue d. Change in nail shape

ANS: A, B, & C Whole-grain foods and beans are high in folic acid.

Which foods should you encourage patients with folic acid deficiency to include in their daily food intake (select all that apply)? a. Ready-to-eat cereal b. Wheat tortillas c. Lentils d. Strawberries e. Potatoes

ANS: A There are many causes of cobalamin (B12) deficiency. The most common cause is pernicious anemia, a disease in which the gastric mucosa is not secreting intrinsic factor (IF) because of antibodies being directed against the gastric parietal cells or IF itself. Other causes of cobalamin deficiency include gastrectomy, gastritis, nutritional deficiency, chronic alcoholism, and hereditary enzymatic defects of cobalamin use.

Which individual is at high risk for a cobalamin (vitamin B12) deficiency anemia? a. A 47-year-old man who had a gastrectomy (removal of the stomach) b. A 54-year-old man with a history of irritable bowel disease and ulcerative colitis c. A 26-year-old woman who complains of heavy menstrual periods d. A 15-year-old girl who is a vegetarian

ANS: C Exposure to crowds increases the patient's risk for infection, the most common cause of sickle cell crisis. There is no restriction on caffeine use. Iron supplementation is generally not recommended. A high-fluid intake is recommended.

Which instruction will the nurse plan to include in discharge teaching for the patient admitted with a sickle cell crisis? a. Take a daily multivitamin with iron. b. Limit fluids to 2 to 3 quarts per day. c. Avoid exposure to crowds when possible. d. Drink only two caffeinated beverages daily.

ANS: A The other interventions focus on preventing venous stasis, clot formation, and myocardial infarction. Using a soft-bristled toothbrush minimizes trauma to the gums and prevents bleeding.

Which intervention is most important for the nurse to teach the client with polycythemia vera to prevent injury as a result of the increased bleeding tendency? a. Use a soft-bristled toothbrush. b. Drink at least 3 liters of liquids per day. c. Wear gloves and socks outdoors in cool weather. d. Exercise slowly and only on the advice of your physician.

ANS: A Eggs and whole grain breads are high in iron. The other choices are appropriate for other nutritional deficiencies but are not the best choice for a patient with iron-deficiency anemia.

Which menu choice indicates that the patient understands the nurse's teaching about best dietary choices for iron-deficiency anemia? a. Omelet and whole wheat toast b. Cantaloupe and cottage cheese c. Strawberry and banana fruit plate d. Cornmeal muffin and orange juice

ANS: D All current assessment findings are important. However, the pain in the hip, the slow capillary refill, and the yellow appearance of the roof of the mouth are related to the crises and are expected. The facial drooping as a new finding indicates the possibility of reduced brain perfusion and stroke. This new development requires immediate attention and intervention.

Which new assessment finding in a client with sickle cell disease who currently is in crises does the nurse report immediately to the health care provider? a. Pain in the right hip with limited range of motion b. Slow capillary refill in the toes of the right foot c. Yellow appearance of the roof of the mouth d. Facial drooping on the right side

ANS: C For all causes of hemolysis, a major focus of treatment is to maintain renal function. When RBCs are hemolyzed, the hemoglobin molecule is released and filtered by the kidneys. The accumulation of hemoglobin molecules can obstruct the renal tubules and lead to acute tubular necrosis

Which organ is at greatest risk due to the effects of hemolytic anemia? a. Heart b. Spleen c. Kidney d. Liver

ANS: A Patients with aplastic anemia are at risk for infection because of the low white blood cell production associated with this type of anemia, so the nurse should avoid assigning a roommate with any possible infectious process.

Which patient should the nurse assign as the roommate for a patient who has aplastic anemia? a. A patient with chronic heart failure b. A patient who has viral pneumonia c. A patient who has right leg cellulitis d. A patient with multiple abdominal drains

ANS: A It is normal for the stools to appear black when a patient is taking iron, and the patient should not call the doctor about this. The other patient statements are correct.

Which patient statement to the nurse indicates a need for additional instruction about taking oral ferrous sulfate? a. "I will call my health care provider if my stools turn black." b. "I will take a stool softener if I feel constipated occasionally." c. "I should take the iron with orange juice about an hour before eating." d. "I should increase my fluid and fiber intake while I am taking iron tablets."

ANS: A & B Avoiding dehydration and high altitudes helps to prevent crises. Vitamins, dairy products, and grapefruit juice cannot help the patient to prevent attacks of sickle cell disease.

Which points should be included in teaching the patient with sickle cell disease (select all that apply)? a. Avoid dehydration. b. Avoid high altitudes. c. Take cobalamin (vitamin B12) regularly. d. Consume dairy products frequently. e. Increase consumption of grapefruit juice.

ANS: D Because infection is the most common cause of a sickle cell crisis, influenza, Haemophilus influenzae, pneumococcal pneumonia, and hepatitis immunizations should be administered. Although continuous dose opioids and oxygen may be administered during a crisis, patients do not receive these therapies to prevent crisis. Hydroxyurea (Hydrea) is a medication used to decrease the number of sickle cell crises.

Which statement by a patient indicates good understanding of the nurse's teaching about prevention of sickle cell crisis? a. "Home oxygen therapy is frequently used to decrease sickling." b. "There are no effective medications that can help prevent sickling." c. "Routine continuous dosage narcotics are prescribed to prevent a crisis." d. "Risk for a crisis is decreased by having an annual influenza vaccination."

ANS: B Specific clinical manifestations may be related to iron-deficiency anemia. Pallor is the most common finding, and glossitis (inflammation of the tongue) is the second most common; another finding is cheilitis (inflammation of the lips). The patient may report headache, paresthesias, and a burning sensation of the tongue, all of which are caused by lack of iron in the tissues. A sore tongue is a sign of cobalamin (B12) deficiency. Tenting skin is a sign of dehydration that often accompanies diarrhea. Blue mucous membranes are associated with cyanosis.

You are caring for a patient with a diagnosis of iron-deficiency anemia. Which clinical manifestations are you most likely to observe when assessing this patient? a. Convex nails, bright red gums, and alopecia b. Brittle nails; smooth, shiny tongue; and cheilosis c. Tenting of the skin, sunken eyes, and complaints of diarrhea d. Pale pink tongue; dull, brittle hair; and blue mucous membranes