MED SURG (NCLEX) Hematology
The primary purpose of the Schilling test is to measure the client's ability to: A Store vitamin B12 B Digest vitamin B12 C Absorb vitamin B12 D Produce vitamin B12
C Absorb vitamin B12 Pernicious anemia is caused by the body's inability to absorb vitamin B12. This results in a lack of intrinsic factor in the gastric juices. Schilling's test helps diagnose pernicious anemia by determining the client's ability to absorb vitamin B12.
The nurse explains to the parents of a 1-year-old child admitted to the hospital in a sickle cell crisis that the local tissue damage the child has on admission is caused by which of the following? A Autoimmune reaction complicated by hypoxia B Lack of oxygen in the red blood cells C Obstruction to circulation D Elevated serum bilirubin concentration.
C Obstruction to circulation Characteristic sickle cells tend to cause "log jams" in capillaries. This results in poor circulation to local tissues, leading to ischemia and necrosis. The basic defect in sickle cell disease is an abnormality in the structure of RBCs. The erythrocytes are sickle-shaped, rough in texture, and rigid. Sickle cell disease is an inherited disease, not an autoimmune reaction. Elevated serum bilirubin concentrations are associated with jaundice, not sickle cell disease.
A client with iron deficiency anemia is scheduled for discharge. Which instruction about prescribed ferrous gluconate therapy should the nurse include in the teaching plan? A "Take the medication with an antacid." B "Take the medication with a glass of milk." C "Take the medication with cereal." D "Take the medication on an empty stomach."
D "Take the medication on an empty stomach." Preferably, ferrous gluconate should be taken on an empty stomach. Ferrous gluconate should not be taken with antacids, milk, or whole-grain cereals because these foods reduce iron absorption.
When a client is diagnosed with aplastic anemia, the nurse monitors for changes in which of the following physiological functions? A Bleeding tendencies B Intake and output C Peripheral sensation D Bowel function
A Bleeding tendencies Aplastic anemia decreases the bone marrow production of RBCs, WBCs, and platelets. The client is at risk for bruising and bleeding tendencies. A change in the intake and output is important, but assessment for the potential for bleeding takes priority. Change in the peripheral nervous system is a priority problem specific to clients with vitamin B12 deficiency. Change in bowel function is not associated with aplastic anemia.
vegetarian client was referred to a dietitian for nutritional counseling for anemia. Which client outcome indicates that the client does not understand nutritional counseling? The client: A Adds dried fruit to cereal and baked goods B Cooks tomato-based foods in iron pots C Drinks coffee or tea with meals D Adds vitamin C to all meals
C Drinks coffee or tea with meals Coffee and tea increase gastrointestinal motility and inhibit the absorption of nonheme iron. Clients are instructed to add dried fruits to dishes at every meal because dried fruits are a nonheme or nonanimal iron source. Cooking in iron cookware, especially acid-based foods such as tomatoes, adds iron to the diet. Clients are instructed to add a rich supply of vitamin C to every meal because the absorption of iron is increased when food with vitamin C or ascorbic acid is consumed.
A clinic nurse instructs the mother of a child with sickle cell disease about the precipitating factors related to pain crisis. Which of the following, if identified by the mother as a precipitating factor, indicates the need for further instructions? A Infection B Trauma C Fluid overload D Stress
C Fluid overload Pain crisis may be precipitated by infection, dehydration, hypoxia, trauma, or physical or emotional stress. The mother of a child with sickle cell disease should encourage fluid intake of 1 ½ to 2 times the daily requirement to prevent dehydration.
The nurse is preparing to teach a client with microcytic hypochromic anemia about the diet to follow after discharge. Which of the following foods should be included in the diet? A Eggs B Lettuce C Citrus fruits D Cheese
A Eggs One of the microcytic, hypochromic anemias is iron-deficiency anemia. A rich source of iron is needed in the diet, and eggs are high in iron. Other foods high in iron include organ and muscle (dark) meats; shellfish, shrimp, and tuna; enriched, whole-grain, and fortified cereals and breads; legumes, nuts, dried fruits, and beans; oatmeal; and sweet potatoes. Dark green leafy vegetables and citrus fruits are good sources of vitamin C. Cheese is a good source of calcium.
The nurse understands that the client with pernicious anemia will have which distinguishing laboratory findings? A Schilling's test, elevated B Intrinsic factor, absent C Sedimentation rate, 16 mm/hour D RBCs 5.0 million
B Intrinsic factor, absent The defining characteristic of pernicious anemia, a megaloblastic anemia, is lack of the intrinsic factor, which results from atrophy of the stomach wall. Without the intrinsic factor, vitamin B12 cannot be absorbed in the small intestines, and folic acid needs vitamin B12 for DNA synthesis of RBCs. The gastric analysis was done to determine the primary cause of the anemia. An elevated excretion of the injected radioactive vitamin B12, which is protocol for the first and second stage of the Schilling test, indicates that the client has the intrinsic factor and can absorb vitamin B12 into the intestinal tract. A sedimentation rate of 16 mm/hour is normal for both men and women and is a nonspecific test to detect the presence of inflammation. It is not specific to anemias. An RBC value of 5.0 million is a normal value for both men and women and does not indicate anemia.
The nurse has just admitted a 35-year-old female client who has a serum B12 concentration of 800 pg/ml. Which of the following laboratory findings would cue the nurse to focus the client history on specific drug or alcohol abuse? A Total bilirubin, 0.3 mg/dL B Serum creatinine, 0.5 mg/dL C Hemoglobin, 16 g/dL D Folate, 1.5 ng/mL
D Folate, 1.5 ng/mL The normal range of folic acid is 1.8 to 9 ng/mL, and the normal range of vitamin B12 is 200 to 900 pg/mL. A low folic acid level in the presence of a normal vitamin B12 level is indicative of a primary folic acid-deficiency anemia. Factors that affect the absorption of folic acid are drugs such as methotrexate, oral contraceptives, antiseizure drugs, and alcohol. The total bilirubin, serum creatinine, and hemoglobin values are within normal limits.
A client was admitted with iron deficiency anemia and blood-streaked emesis. Which question is most appropriate for the nurse to ask in determining the extent of the client's activity intolerance? A "What activities were you able to do 6 months ago compared with the present?" B "How long have you had this problem?" C "Have you been able to keep up with all your usual activities?" D "Are you more tired now than you used to be?"
A "What activities were you able to do 6 months ago compared with the present?" It is difficult to determine activity intolerance without objectively comparing activities from one time frame to another. Because iron deficiency anemia can occur gradually and individual endurance varies, the nurse can best assess the client's activity tolerance by asking the client to compare activities 6 months ago and at the present. Asking a client how long a problem has existed is a very open-ended question that allows for too much subjectivity for any definition of the client's activity tolerance. Also, the client may not even identify that a "problem" exists. Asking the client whether he is staying abreast of usual activities addresses whether the tasks were completed, not the tolerance of the client while the tasks were being completed or the resulting condition of the client after the tasks were completed. Asking the client if he is more tired now than usual does not address his activity tolerance. Tiredness is a subjective evaluation and again can be distorted by factors such as the gradual onset of the anemia or the endurance of the individual.
A client with pernicious anemia asks why she must take vitamin B12 injections for the rest of her life. What is the nurse's best response? A "The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient acid." B "The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient intrinsic factor." C "The reason for your vitamin deficiency is an excessive excretion of the vitamin because of kidney dysfunction." D "The reason for your vitamin deficiency is an increased requirement for the vitamin because of rapid red blood cell production."
B "The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient intrinsic factor." Most clients with pernicious anemia have deficient production of intrinsic factor in the stomach. Intrinsic factor attaches to the vitamin in the stomach and forms a complex that allows the vitamin to be absorbed in the small intestine. The stomach is producing enough acid, there is not an excessive excretion of the vitamin, and there is not a rapid production of RBCs in this condition.
The nurse devises a teaching plan for the patient with aplastic anemia. Which of the following is the most important concept to teach for health maintenance? A Eat animal protein and dark leafy vegetables each day B Avoid exposure to others with acute infection C Practice yoga and meditation to decrease stress and anxiety D Get 8 hours of sleep at night and take naps during the day
B Avoid exposure to others with acute infection Clients with aplastic anemia are severely immunocompromised and at risk for infection and possible death related to bone marrow suppression and pancytopenia. Strict aseptic technique and reverse isolation are important measures to prevent infection. Although diet, reduced stress, and rest are valued in supporting health, the potentially fatal consequence of an acute infection places it as a priority for teaching the client about health maintenance. Animal meat and dark green leafy vegetables, good sources of vitamin B12 and folic acid, should be included in the daily diet. Yoga and meditation are good complimentary therapies to reduce stress. Eight hours of rest and naps are good for spacing and pacing activity and rest.
The nurse implements which of the following for the client who is starting a Schilling test? A Administering methylcellulose (Citrucel) B Starting a 24- to 48 hour urine specimen collection C Maintaining NPO status D Starting a 72 hour stool specimen collection
B Starting a 24- to 48 hour urine specimen collection Urinary vitamin B12 levels are measured after the ingestion of radioactive vitamin B12. A 24-to 48- hour urine specimen is collected after administration of an oral dose of radioactively tagged vitamin B12 and an injection of non-radioactive vitamin B12. In a healthy state of absorption, excess vitamin B12 is excreted in the urine; in a malabsorption state or when the intrinsic factor is missing, vitamin B12 is excreted in the feces. Citrucel is a bulk-forming agent. Laxatives interfere with the absorption of vitamin B12. The client is NPO 8 to 12 hours before the test but is not NPO during the test. A stool collection is not part of the Schilling test. If stool contaminates the urine collection, the results will be altered.
The nurse would instruct the client to eat which of the following foods to obtain the best supply of vitamin B12? A Whole grains B Green leafy vegetables C Meats and dairy products D Broccoli and Brussels sprouts
C Meats and dairy products Good sources of vitamin B12 include meats and dairy products. Whole grains are a good source of thiamine. Green leafy vegetables are good sources of niacin, folate, and carotenoids (precursors of vitamin A). Broccoli and Brussels sprouts are good sources of ascorbic acid (vitamin C).
A client comes into the health clinic 3 years after undergoing a resection of the terminal ileum complaining of weakness, shortness of breath, and a sore tongue. Which client statement indicates a need for intervention and client teaching? A "I have been drinking plenty of fluids." B "I have been gargling with warm salt water for my sore tongue." C "I have 3 to 4 loose stools per day." D "I take a vitamin B12 tablet every day.
D "I take a vitamin B12 tablet every day. Vitamin B12 combines with intrinsic factor in the stomach and is then carried to the ileum, where it is absorbed in the bloodstream. In this situation, vitamin B12 cannot be absorbed regardless of the amount of oral intake of sources of vitamin B12 such as animal protein or vitamin B12 tablets. Vitamin B12 needs to be injected every month, because the ileum has been surgically removed. Replacement of fluids and electrolytes is important when the client has continuous multiple loose stools on a daily basis. Warm salt water is used to soothe sore mucous membranes. Crohn's disease and small bowel resection may cause several loose stools a day.
