Chapters 30-35
A patient's family member asks what hematopoiesis is. What should the nurse tell the family member? A) The manufacture and development of blood cells B) The production of lymphatic fluid in the body C) The making of red blood cells and lymph D) The development of lymph in the bone marrow
Ans: A Feedback: Hematopoiesis is the manufacture and development of blood cells. It also considers the lymphatic system, which includes the thymus gland and spleen; this system assists in the maturation of certain lymphocytes. Hematopoiesis is not the production of lymphatic fluid or the development of lymph in the bone marrow.
A client has laboratory studies that determine he is deficient in copper. What does the nurse understand is the importance of copper in the body? A) Essential for the maturation of red blood cells B) Basic nutritional component of heme in hemoglobin C) Involved in the transfer of iron from storage to plasma D) Serves as a coenzyme in hemoglobin formation
Ans: C Feedback: Copper is involved in the transfer of iron from storage to plasma. Folic acid and B12 are essential for the maturation of red blood cells. Iron is the basic nutritional component of heme in hemoglobin. Vitamin B6 serves as a coenzyme in hemoglobin formation.
The nurse is assisting the physician with obtaining a sample to determine the status of blood cell formation. What type of procedure will the nurse have prepared the client for? A) A bone marrow aspiration B) A Schilling test C) A thoracentesis D) A urine sample
Ans: A Feedback: A bone marrow aspiration is performed to determine the status of blood cell formation. In this procedure, the physician applies local anesthesia and removes bone marrow from the posterior iliac crest or the sternum. The marrow is examined for the types and percentage of immature and maturing blood cells.
When obtaining vital signs from a client who has reduced erythrocyte production and a hemoglobin level of 8.2 g/dL, what results would be indicative of these lab studies? A) Heart rate of 120 beats/minute B) Respiratory rate of 16 breaths/minute C) Blood pressure of 140/90 mm Hg D) Oxygen saturation of 95%
Ans: A Feedback: A rapid pulse rate can indicate reduced erythrocytes or inadequate hemoglobin levels. The respiratory rate for this client is within normal range. Hypertension is not indicative of a low hemoglobin level, and what is usually seen would be hypotension. The oxygen saturation level is within normal range.
A client is taking a medication that has the side effect of depressing the hematopoietic system. What signs of leukopenia should the nurse monitor for while the client is taking this drug? A) Fever, sore throat, and chills B) Nausea and vomiting C) Diarrhea, diaphoresis, and fever D) Intolerance to heat and rash
Ans: A Feedback: Closely monitor clients taking medications that depress the hematopoietic system, particularly thrombocytes and leukocytes. Signs of leukopenia include fever, sore throat, and chills. Nausea and vomiting, diarrhea, diaphoresis, heat intolerance, and rash are not indicative of leukocytosis.
A client informs the nurse that he is having a difficult time coping with seasonal allergies and have taken some over-the-counter medications to assist with control of symptoms. What results would indicate to the nurse that the client does have allergies? A) Elevated eosinophils B) Elevated basophils C) Elevated monocytes D) Elevated neutrophils
Ans: A Feedback: Eosinophils phagocytize foreign material. Their numbers increase in allergies, some dermatologic disorders, and parasitic infections. Basophils are also capable of phagocytosis; they are active in allergic contact dermatitis and some delayed hypersensitivity reactions. Monocytes engulf microbial invaders and display the antigenic surface to T lymphocytes. Neutrophils are a major component of the inflammatory response and defense against bacterial infection.
A client is seeing the physician at the clinic and tells the nurse he is fatigued and short of breath with minimal exertion. What lab study may reflect a decrease in transport of oxygen? A) Erythrocyte count B) Leukocyte count C) Platelet count D) Albumin level
Ans: A Feedback: Erythrocytes function is to transport oxygen. Leukocytes protect against infection. Platelets participate in clotting blood, and albumin affects intravascular osmotic pressure.
The nurse is assisting the physician to control the bleeding for a client who has had an insertion of a vascular access. What can the nurse obtain for the physician to use to control the bleeding? A) A fibrin sponge B) Injection of alpha globulins C) Albumin D) Injection of beta globulins
Ans: A Feedback: Fibrinogen plays a key role in forming blood clots. It can be transformed from a liquid to fibrin, a solid that controls bleeding. Alpha and beta globulins function primarily as immunologic agents; they prevent or modify some types of infectious diseases. The help maintain osmotic pressure in the vascular compartment. Albumin is formed in the liver and is the most abundant protein in plasma but does not stop vessel bleeding.
A nurse is providing care to a cancer patient. Which protein in plasma functions primarily as immunologic agents? A) Gamma globulins B) Albumin C) Fibrinogen D) Beta globulins
Ans: A Feedback: Globulins are divided into three groups: alpha, beta, and gamma. The gamma globulins are also called immunoglobulins. Globulins function primarily as immunologic agents; they prevent or modify some types of infectious diseases. Therefore options B, C, and D are incorrect.
A student nurse is having difficulty understanding the function of globulins. What information can you provide to the student? A) Immunologic agents B) Destruction of invading organisms C) Precursors to clot formation D) Transport of oxygen to the tissues
Ans: A Feedback: Globulins function primarily as immunologic agents; they prevent or modify some types of infectious diseases. Globulins do not destroy invading organisms, participate in clot formation, or transport oxygen to the tissues.
A client is admitted to the emergency department with significant blood loss. The physician orders 2 units of packed red blood cells to be transfused immediately. Which blood groups would be compatible with his O Rh-positive blood group? A) O Rh-positive or O Rh-negative B) Only O Rh-positive C) Only O Rh-negative D) AB Rh-positive or Rh-negative
Ans: A Feedback: People with Rh-positive blood can receive Rh-positive or Rh-negative blood because a negative Rh indicates a missing Rh factor. Antibodies, immunoglobulins in plasma that inactivate any substance that is nonself, react with incompatible red blood cell antigens. Therefore, people with type O blood are universal donors because they do not have antigens on the red cell membrane. Therefore, the client can be transfused with either O Rh-positive or O Rh-negative blood.
A client is volunteering to donate blood for the second time and was mailed a letter telling him that he has type AB blood. If the client requires a blood transfusion in the future, what type of blood must he receive? A) They can receive blood from persons with any type of blood if the RH factor is compatible. B) They can only receive blood from persons with type A blood. C) They can only receive blood from persons with type B blood. D) They can only receive blood from persons with type O blood if the RH factor is positive.
Ans: A Feedback: People with type AB blood are considered universal recipients because both A and B antigens are present on the red cell membrane. Clients with type AB blood can receive blood from persons with any type of blood, but the Rh factor must be compatible. The other distractors are incorrect because the client can receive blood from any type.
The nurse observes that a client who had an arterial blood gas performed 30 minutes ago is still oozing blood from the puncture site. Pressure was held to the site for 5 minutes after the puncture and another 5 minutes when the site was still oozing. What factor does the nurse know will participate in the ability for the blood to clot? A) Platelets B) Leukocytes C) Erythrocytes D) Albumin
Ans: A Feedback: Platelets participate in clotting blood. Leukocytes protect against infection. Erythrocytes transport oxygen, and albumin affects intravascular osmotic pressure.
The nurse will be assisting the physician with a bone marrow aspiration. Where should the nurse cleanse, clip hair, and drape the skin prior to the procedure? A) Over the posterior superior iliac crest B) Over the anterior tibia C) Over the radius D) Over the metatarsal area
Ans: A Feedback: The posterior superior iliac crest is the preferred site because no vital organs or blood vessels are nearby. The anterior tibia, radius, or metatarsal area are not used for bone marrow aspirations.
Macrophages attack and destroy foreign substances to the body. Where does this action occur? A) At the site of trauma B) In the lymph node C) In the vascular system D) In the thymus
Ans: B Feedback: As lymph passes through the node, macrophages attack and engulf foreign substances such as bacteria and viruses, abnormal body cells, and other debris. Options A, C, and D are incorrect.
You are caring for three clients who have the following blood count values: Client A has 24,500/mm3 white blood cells (WBCs), client B has 13.4 g/dL hemoglobin, and client C has a 250,000/mm3 platelet count. Which statement correctly describes the condition of each client? A) Client A has a normal WBC count, client B has a higher hemoglobin count than normal, and client C has a normal platelet count. B) Client A has a higher WBC count than normal, client B has a normal hemoglobin count, and client C has a normal platelet count. C) Client A has a higher WBC count than normal, client B has a normal hemoglobin count, and client C has a higher platelet count than normal. D) Client A has a normal WBC count than normal, client B has a normal hemoglobin count, and client C has a normal platelet count.
Ans: B Feedback: The normal leukocyte count is between 5000 and 10,000/mm3. Client A has an increased number of leukocytes greater than 10,000/mm3 and hence has leukocytosis. In adults, the normal amount of hemoglobin is 12.0 to 17.4 g/dL; therefore, client B has a normal hemoglobin count. A normal circulating platelet count is 150,000 to 350,000/mm3 platelets; therefore, client C has a normal platelet count.
A client has been involved in an automobile accident and is assessed to have an enlarged spleen. What does the nurse understand is the significance of attempting to prevent unnecessary removal of the spleen for this client? A) The spleen is a large lymph node and takes waste debris away. B) The spleen is a lymphatic structure and assists with phagocytosis. C) The spleen is lymphoid tissue in the upper chest that contains stem cells. D) The spleen assists with blood clotting.
Ans: B Feedback: The spleen is the largest lymphatic structure, is a reservoir of blood, and contains phagocytes that engulf damaged erythrocytes and foreign substances. Lymph fluid takes waste debris away. The thymus is lymphoid tissue that is in the upper chest and contains stem cells. The spleen does not assist with blood clotting.
The nurse is discussing vitamin replacement with a client in the clinic. Which vitamin should the nurse discuss with the client in order to increase the absorption of folic acid and iron? A) Vitamin B12 B) Vitamin C C) Vitamin B6 D) Vitamin E
Ans: B Feedback: Vitamin C enhances the absorption of folic acid and iron. Vitamin B12 and folic acid are essential for the maturation of red blood cells. Vitamin B6 serves as a coenzyme in hemoglobin formation. Vitamin E protects blood cells from vitamin E-deficient hemolytic anemia.
A client is scheduled for a Schilling test in the morning. What diagnostic results would be indicated if the test is positive? Select all that apply. A) Iron-deficiency anemia B) Pernicious anemia C) Macrocytic anemia D) Malabsorption syndromes E) A gastric ulcer
Ans: B, C, D Feedback: A Schilling test is used to diagnose pernicious anemia, macrocytic anemia, and malabsorption syndromes. A blood test to determine iron-deficiency anemia would be diagnostic. A gastric ulcer can be determined with a gastroesophagoscopy.
The nurse is inspecting the tonsils of a client that complaints of a sore throat for size and appearance. What is the appropriate documentation for an observation of tonsils that touch the uvula? A) 1 B) 2 C) 3 D) 4
Ans: C Feedback: A scale of 3 is when the tonsils touch the uvula. A 1 is when the tonsils are visible, a 2 is when the tonsils extend medially toward the uvula, and a 4 is when the tonsils touch each other.
The nursing instructor is teaching her clinical group about laboratory blood tests. What is the major function of erythrocytes? A) Act as mediators for the immune system B) Destroy invading organisms C) Transportation of O2 to the tissues and removal of CO2 from the tissues D) Oxygenation of the brain
Ans: C Feedback: Erythrocytes (or RBCs) are flexible, anuclear (lacking a nucleus), biconcave disks covered by a thin membrane through which oxygen (O2) and carbon dioxide (CO2) pass freely. The flexibility of erythrocytes allows them to change shape as they travel through capillaries. Their major function is to transport O2 to and remove CO2 from the tissues. The RBCs are not involved in immunological functions, so choices A and B are not correct. Oxygenation of the brain is important but that is not a major function of RBCs.
The nurse is observing the skin of a client who is taking medications that depress the hematopoietic system and notices multiple areas of ecchymosis on the arms; bleeding for a prolonged period after an IV was started; and reports of black, tarry stool. What does the nurse understand may be a side effect of this medication that the client displays? A) Leukocytosis B) Leukopenia C) Thrombocytopenia D) Neutropenia
Ans: C Feedback: Signs of thrombocytopenia include unusual or easy bleeding; oozing from injection sites; bleeding gums; and dark, tarry stools. Leukocytosis would cause fever as well as other signs and symptoms of infection. Leukopenia symptoms are fever, sore throat, and chills. Neutropenia reduces the client's ability to fight infection and makes susceptible to microorganisms.
A client is scheduled for a bone marrow aspiration and is extremely apprehensive about having the procedure done. The nurse explains that there may be a feeling of pressure or discomfort when puncturing the bone. What intervention can the nurse provide to assist with this concern? A) Inform the client that he will not be able to move and will have to tolerate the discomfort for 20 minutes. B) Inform the client that if he is concerned that he will move when the bone is punctured, soft wrist restraints can be used if the client approves. C) Assist the client with focused imagery to avoid focusing on the procedure and any discomfort associated with it. D) Suggest chewing gum or eating candy in order to focus on something other than the discomfort.
Ans: C Feedback: Suggest distraction techniques to avoid focusing on the pressure or discomfort associated with puncturing the bone that may take approximately 20 minutes. Restraints should not be applied during the procedure because the client may not be able to determine if they are too tight. The client has a right to pain relief and should not have to "tolerate" pain for 20 minutes. Chewing gum or eating candy may increase the client's risk for aspiration during the procedure.
The nurse is preparing the client for a bone marrow aspiration at the posterior iliac crest. What would be the best position for the nurse to place the client in for the test? A) Head of the bed in a 90° semi-Fowler's position B) Prone position C) On the side opposite the aspiration site D) Lithotomy position
Ans: C Feedback: The client should be positioned on his or her back or side to facilitate access to the aspiration site. The 90° semi-Fowler's and prone position would not allow adequate access to the bone marrow aspiration site. The lithotomy position is used for genitourinary and gynecological testing and procedures.
A client with end-stage renal disease has a decreased red blood cell production. What medication can the nurse administer with physician's order that will increase the production of erythrocytes? A) Filgrastim (Neupogen) B) Pegfilgrastim (Neulasta) C) Epoetin alfa (Epogen) D) Interleukin 2
Ans: C Feedback: The drug epoetin alfa (Epogen, Procrit) can be used to stimulate the production of RBCs. Filgrastim (Neupogen) and pegfilgrastim (Neulasta) promote proliferation of neutrophils. Interleukin 2 stimulates cytokine production by lymphocytes.
A client is brought to the emergency department with suspected bleeding esophageal varices. Which hemoglobin level should the nurse immediately report to the physician? A) 13.0 g/dL B) 10.2 g/dL C) 5.0 g/dL D) 11.4 g/dL
Ans: C Feedback: The nurse should immediately report a 5.0 g/dL, which is a critical low level and should be followed by a blood transfusion. A 13.0 g/dL is a normal level, 11.4 is slightly low, and 10.2 is low.
Undifferentiated cells that migrate to the thymus gland develop into which of the following? A) A lymphocytes B) D lymphocytes C) T lymphocytes D) S lymphocytes
Ans: C Feedback: The thymus gland is lymphatic tissue in the upper chest that contains undifferentiated stem cells released from bone marrow. Once the undifferentiated cells migrate to the thymus gland, they develop into T lymphocytes because they are thymus derived. Options A, B, and D are distractors for this question.
Albumin is a protein in the plasma portion of the blood. Under normal conditions, albumin cannot pass through the wall of a capillary. What significance is this for the vascular compartment? A) Helps push oxygen into the tissues of the body B) Retains leukocytes in the vascular compartment C) Helps retain fluid in the vascular compartment D) Absorbs carbon dioxide from the tissues for transport to the lungs
Ans: C Feedback: Under normal conditions, albumin cannot pass through a capillary wall. Consequently, albumin helps maintain the osmotic pressure that retains fluid in the vascular compartment. Albumin does not push oxygen into the tissues of the body or absorb carbon dioxide for transport to the lungs. Albumin also does not retain leukocytes in the vascular compartment.
A client is being treated for anemia and has a hemoglobin level of 9.6 g/dL. What does the nurse understand is the basic nutritional component of heme in hemoglobin that the client may be deficient in? A) Folic acid B) Copper C) Protein D) Iron
Ans: D Feedback: Iron is the basic nutritional component of heme in hemoglobin. Folic acid is essential for the maturation of red blood cells. Copper (minute amount) is involved in the transfer of iron from storage to plasma.
The nurse is inspecting the tonsils for a client with a fever and sore throat. The nurse observes purulent exudate on the surface of the tonsils. What does this finding indicate to the nurse? A) Filariasis B) Thrush C) An abscess D) Tonsillitis
Ans: D Feedback: Purulent exudate on the surface of the tonsils suggests tonsillitis. Filariasis is also known as elephantiasis and is a consequence of a roundworm infection in which the lymphatic vessels become occluded. An abscess would not have purulent drainage on the surface unless ruptured.
Why would it be important for the nurse to obtain information regarding dietary history of a client with a possible abnormality of the hematopoietic or lymphatic system? A) It could determine if the illness is self-induced by nutritional starvation. B) If the client has impaired protein intake, it will cause diseases of the hematopoietic system. C) Altered nutrition is the cause of abnormalities of the hematopoietic and lymphatic system. D) Compromised nutrition interferes with production of blood cells and hemoglobin.
Ans: D Feedback: The nurse obtains a dietary history because compromised nutrition interferes with the production of blood cells and hemoglobin. The history cannot determine if the illness is self- induced by starvation. Nutritional deficiencies do not cause diseases of the hematopoietic system and lymphatic system.
A client is in the hospital with a bleeding gastric ulcer and requires a blood transfusion. He has been typed and crossmatched for 2 units of packed red blood cells and found to have type O blood. What type of blood will the nurse administer to this client? A) Type A B) Type B C) Type AB D) Type O
Ans: D Feedback: Those with type O blood can only receive type O blood. Clients with all other blood types can receive type O blood provided the Rh factor is compatible.
You are caring for a client who is undergoing bone marrow aspiration to determine the blood cell formation status. What nursing intervention should you provide to your client during the test? A) Administer oral radioactive vitamin B12 to the client. B) Administer a nonradioactive B12 injection. C) Collect urine for 24 to 48 hours after the client receives the nonradioactive B12. D) Support the client and monitor the status.
Ans: D Feedback: When a client undergoes a bone marrow aspiration, the nurse assists the physician, supports the client during the procedure, and monitors his or her condition afterward. The client needs to be administered oral radioactive vitamin B12 or a nonradioactive B12 injection in case of the Schilling test, which helps in determining pernicious anemia and macrocytic anemia. Collecting urine for 24 to 48 hours after administering nonradioactive B12 is also applicable to the Schilling test.
23. A 15-year-old client arrives at the clinic and informs the nurse that he attended 2 weeks of summer camp last month and now is not feeling well with complaints of sore throat, fever, and very tired. The nurse observes white exudate on the tonsils. What test does the nurse anticipate the physician will order for this client? A) Monospot test B) AST and ALT C) Glucose level D) T3, T4, and TSH
Ans: A Feedback: A positive slide agglutination test (Monospot, Monotest, Monosticon) is presumptive evidence that the Epstein-Barr virus is causing the symptoms. A rise in the Epstein-Barr virus antibody titer and a heterophil agglutination test result of 1:224 or greater is conclusive for infectious mononucleosis. The AST and ALT would indicate possible liver disorders. A glucose level would not be indicative of Epstein-Barr virus. T3, T4, and TSH would be indicative of thyroid dysfunction, which the client's age and symptoms do not correlate with.
18. A client has developed an infection that resulted in lymphangitis. What does the nurse suspect the causative organism is that caused the infection? A) A streptococcal microorganism B) A Staphylococcus microorganism C) Escherichia coli D) Candida albicans
Ans: A Feedback: An infectious agent, commonly a streptococcal microorganism, usually causes both lymphangitis and lymphadenitis. It is not commonly caused by staph, E. coli, or C. albicans (a fungal infection).
26. The nurse is caring for a client with a diagnosis of Hodgkin's disease and is aware that there is enlargement of the retroperitoneal nodes when reviewing the review of systems on the physician's history and physical. What symptoms are the nurse aware may be indicative of enlargement of the retroperitoneal nodes? A) Complaints of a sense of fullness in the stomach and epigastric pain B) Sore throat, white discharge on the tonsils C) Nausea and vomiting D) Respiratory rate of 14 and shallow
Ans: A Feedback: As retroperitoneal nodes enlarge, there is a sense of fullness in the stomach and epigastric pain in clients with Hodgkin's disease. A sore throat and white discharge on the tonsils may be indicative of a throat infection or infectious mononucleosis. Nausea and vomiting are vague symptoms that are related to many disorders and diseases. Respiratory symptoms do not indicate Hodgkin's disorders related to retroperitoneal node enlargement.
2. A client has just been admitted to your unit with a diagnosis of Hodgkin's disease. When doing the initial assessment, what pertinent questions should the nurse ask the client to help determine the correct nursing diagnosis? A) Are you experiencing fever, chills, or night sweats? B) Do you use artificial respirators? C) Have you ever had a blood transfusion? D) Have you ever experienced fractures?
Ans: A Feedback: In a client with Hodgkin's disease, the nurse should ask how long the client has noticed the enlarged lymph nodes. The nurse checks for the presence and the extent of tenderness in the area of the lymph node enlargement. The nurse should also ask the client about fever, chills, or night sweats. It is not pertinent to ask the client about any previous history of fractures, the use of artificial respirators, or any blood transfusions.
11. A client had a left radical mastectomy with an axillary node dissection 6 months ago and is having a large amount of edema in the left arm down to the fingers. What should the nurse inform the client is the reason for the edema? A) An accumulation of lymphatic fluid that results from impaired lymph circulation. B) It is congenitally acquired and is not related to the mastectomy. C) They are most likely ingesting too much sodium and should be advised to decrease the amount. D) There is inadequate blood flow from circulatory impairment.
Ans: A Feedback: Lymphedema is an accumulation of lymphatic fluid that results from impaired lymph circulation. It is a complication resulting from the removal of multiple lymph nodes at the time of mastectomy or radiation for cancer. It may be congenitally acquired, but in this situation, it is secondary and related to the mastectomy. Sodium intake would not be related to the accumulation of lymph fluid and would be generalized. There is not circulatory impairment from decreased blood flow but impaired lymphatic flow.
33. A client has been diagnosed with non-Hodgkin's lymphoma but has no symptoms at this time. The client has received radiation and chemotherapy with responsiveness to this treatment. How would this disease be classified according to the lack of symptoms and responsiveness to treatment? A) Indolent B) Aggressive C) Cured D) Immunosuppressed
Ans: A Feedback: Non-Hodgkin's lymphoma is classified as either indolent, meaning that the client is relatively asymptomatic at diagnosis, and the disorder is relatively responsive to radiation and chemotherapy; or aggressive, because the condition has a shorter onset with acute symptoms. There is no classification considered cured or immunosuppressed.
35. Which client does the nurse recognize as most likely to be diagnosed with non-Hodgkin's lymphoma rather than Hodgkin's lymphoma? A) A 55-year-old client with AIDS B) A 35-year-old client with type 2 diabetes mellitus C) A 20-year-old client with infectious mononucleosis D) A 40-year-old client with Reed-Sternberg cells in an axillary lymph node
Ans: A Feedback: Non-Hodgkin's lymphoma peak onset is after 50 years and is common among clients with immunosuppression. There is no correlation with client that has diabetes and non-Hodgkin's lymphoma. Forty percent of affected clients test positive for Epstein-Barr virus that causes infectious mononucleosis and that test positive for Reed-Sternberg cells in the lymph nodes that are correlated with Hodgkin's lymphoma.
27. A client is having a lymph node biopsy for suspicion of Hodgkin's disease. What type of cells would be identifiable in the lymph node biopsy that may indicate this disease process? A) Reed-Sternberg cells B) Sickled cells C) Epstein-Barr virus D) Red blood cells
Ans: A Feedback: The Reed-Sternberg cells, characterized as giant multinucleated B lymphocytes, are microscopically identifiable in lymph node biopsies. Sickled red blood cells would indicate sickle cell disease but would be identifiable in a blood test, not a lymph node biopsy. The Epstein-Barr virus is linked to the development of Hodgkin's disease, but the virus is not identified in the lymph node biopsy. Red blood cells would be seen normally on blood tests.
The nurse observes the laboratory studies for a client in the hospital with fatigue, feeling cold all of the time, and hemoglobin of 8.6 g/dL and a hematocrit of 28%. What finding would be an indicator of iron-deficiency anemia? A) Erythrocytes that are microcytic and hypochromic B) Erythrocytes that are macrocytic and hyperchromic C) Clustering of platelets with sickled red blood cells D) An increased number of erythrocytes
Ans: A Feedback:A blood smear reveals erythrocytes that are microcytic (smaller than normal) and hypochromic (lighter in color than normal). It does not reveal macrocytic (larger than normal) or hyperchromic erythrocytes. Clustering of platelets with sickled red blood cells would indicate sickle cell anemia. An increase in the number of erythrocytes would indicate polycythemia vera.
The nurse is admitting a client with Cooley's anemia to the hospital with a hemoglobin of 6.2 g/dL and hematocrit of 26%. What does the nurse document about the client's skin? A) Bronzing of the skin B) Jaundice of the skin and mucous membranes C) Ruddy complexion D) Pale skin and mucous membranes
Ans: A Feedback:Clients with Cooley's anemia, a severe form of beta-thalassemia, exhibit symptoms of severe anemia and a bronzing of the skin caused by hemolysis of erythrocytes. The client is not jaundice, ruddy, or pale with this disorder.
A client comes to the walk-in clinic complaining of weakness and fatigue. While assessing this client, you find evidence of petechiae and ecchymoses. You note that the spleen appears enlarged. What would you suspect is wrong with this client? A) Aplastic anemia B) Pernicious anemia C) Iron-deficiency anemia D) Agranulocytosis
Ans: A Feedback:Clients with aplastic anemia experience all the typical characteristics of anemia (weakness and fatigue). In addition, they have frequent opportunistic infections plus coagulation abnormalities that are manifested by unusual bleeding, small skin hemorrhages called petechiae, and ecchymoses (bruises). The spleen becomes enlarged with an accumulation of the client's blood cells destroyed by lymphocytes that failed to recognize them as normal cells, or with an accumulation of dead transfused blood cells. The blood cell count shows insufficient numbers of blood cells. A bone marrow aspiration confirms that the production of stem cells is suppressed. This scenario does not describe a client with pernicious anemia, iron-deficiency anemia, or agranulocytosis.
The nurse is caring for a client who is having a sickle cell crisis. Which order for analgesia should the nurse consult with the physician? A) Meperedine (Demerol) B) Morphine sulfate C) Sublimaze (Fentanyl) D) Buprenorphine (Buprenex)
Ans: A Feedback:Consult the physician if meperidine (Demerol) is prescribed for treating pain in clients with sickle cell crisis. The liver converts meperidine to normeperidine, which is toxic. Grand mal seizures can result. The other medications are acceptable alternatives to Demerol.
The nurse caring for an older adult with a diagnosis of leukemia would encourage the client to use an electric razor. Why? A) Trauma and micro abrasions may contribute to anemia. B) Fragile tissues and altered clotting mechanisms may result in hemorrhage. C) The client is at risk for spontaneous and uncontrolled bleeding. D) The client is at risk for infection from microorganisms.
Ans: A Feedback:In a client with leukemia who is at risk for hemorrhage, the nurse handles the client gently when assisting and encourages the client to use electric razors. Trauma and microabrasions from razors may contribute to anemia from bleeding. Fragile tissues and altered clotting mechanisms may result in hemorrhage even after minor trauma. Therefore, the nurse inspects the skin for signs of bruising and petechiae and reports melena, hematuria, or epistaxis (nosebleeds). The risks for spontaneous and uncontrolled bleeding or infection from microorganisms are not addressed by the use of electric razors.
A client diagnosed with polycythemia vera has come into the clinic because he has developed a nighttime cough, fatigue, and shortness of breath. What complication would you suspect in this client? A) Stroke B) Tissue infarction C) Congestive heart failure D) Pulmonary embolus
Ans: C Feedback:The symptoms exhibited by this client are indicative of congestive heart failure. Complications include hypertension, congestive heart failure, stroke, tissue and organ infarction, and hemorrhage. Stroke would present with headache, aphasia, and/or numbness in extremities. Tissue infarction would involve extremity discoloration or an organ failure. Pulmonary embolism would be associated with chest pain.
The nurse is caring for an older adult client who has a hemoglobin of 9.6 g/dL and a hematocrit of 34%. To determine where the blood loss is coming from, what intervention can the nurse provide? A) Observe stools for blood. B) Observe the gums for bleeding after the client brushes teeth. C) Observe the sputum for signs of blood. D) Observe client for facial droop.
Ans: A Feedback:Iron-deficiency anemia is unusual in older adults. Normally, the body does not eliminate excessive iron, causing total body iron stores to increase with age and necessitating maintenance of hydration. If an older adult is anemic, blood loss from the gastrointestinal or genitourinary tracts is suspected. Observing the stool for blood will help detect blood from GI loss. Bleeding gums may indicate periodontal disease, or anticoagulation from medication is not related to age. Blood in sputum can be an indicator of various lung disorders that may affect all age groups. Facial droop may indicate an impending stroke or Bell's palsy and would not be a reason for blood loss.
The nursing instructor is discussing disorders of the hematopoietic system with the pre-nursing pathophysiology class. What disease would the instructor list with a primary characteristic of erythrocytosis? A) Polycythemia vera B) Sickle cell disease C) Aplastic anemia D) Pernicious anemia
Ans: A Feedback:Polycythemia vera is associated with a rapid proliferation of blood cells produced by the bone marrow. In sickle cell disease, HbS causes RBCs to assume a sickled shape under hypoxic conditions. Aplastic anemia has a deficiency of erythrocytes. Options B, C, and D do not have the characteristics of erythrocytosis.
A client is experiencing chronic hypovolemic anemia as evidenced by laboratory results. What symptoms does the nurse expect to find for this client when collecting objective data? A) Postural hypotension B) Urinary output of 10 mL/hr C) Altered consciousness D) Extreme pallor
Ans: A Feedback:Symptoms of chronic hypovolemic anemia include pallor, fatigue, chills, postural hypotension, and rapid heart rate and respiratory rates. The symptom of decreased urinary output, altered consciousness, and extreme pallor are all signs of acute hypovolemic anemia from severe blood loss. These signs indicate hypovolemic shock.
A 15-year-old client with hemophilia sustains a leg laceration after falling off of his skateboard and is brought to the emergency department. The laceration is bleeding profusely even with direct pressure to the site. What does the nurse anticipate will be ordered for administration to control bleeding? A) Fresh frozen plasma B) A colloid solution such as hetastarch (Hespan) C) A crystalloid solution such as lactated Ringer's D) Albumin
Ans: A Feedback:Treatment includes transfusion of fresh blood, frozen plasma, factor VIII concentrate, and anti-inhibitor coagulant complex for hemophilia A, factor IX concentrate for hemophilia B, factor XI for hemophilia C, and the application of thrombin or fibrin to the bleeding area. Other measures used to help control bleeding are the administration of fresh frozen plasma, aminocaproic acid (Amicar) that helps to hold a clot in place once it has formed, direct pressure over the bleeding site, and cold compresses or ice packs. Hespan, lactated Ringer's, or albumin will not control the bleeding related to hemophilia.
31. The nurse is providing instruction on the use of compression garments for the client with lymphedema. What should be included in the instructions? Select all that apply. A) Purchase two compression garments. B) Change the garment in the morning and in the evening. C) Limit the time the garment is not worn to 30 to 60 minutes. D) Replace a compression garment every month. E) Place the garment in the dryer after washing.
Ans: A, B, C Feedback: When instructing the client on use of the compression garment, purchase two compression garments so that one can be worn while the other is washed and dried. Change the garment in the morning and again in the evening because the garment becomes stretched after 12 hours of being worn. Limit the time that the garment is not worn to no more than 30 to 60 minutes to prevent reaccumulation of tissue fluid and stretched skin. The garment should be replaced every 4 to 6 months, not every month. The garment should be air dried, not placed in the dryer.
The registered nurse (RN) and licensed practical nurse (LPN) are preparing an educational program for clients who may be at risk for the development of iron-deficiency anemia. Which clients would receive the greatest benefit from this program? Select all that apply. A) A young female client with bulimia nervosa B) An older adult client on a fixed income C) A client with Crohn's disease D) A client who lives in a nursing home E) A client who is a vegetarian
Ans: A, B, C Feedback:Those who consume a healthy diet absorb less than 10% of the iron in food. Clients whose nutrition is compromised by unhealthy dieting or who cannot afford to eat a healthy diet, lack knowledge about nutrition, or have malabsorption disorders are at great risk for iron-deficiency anemia. A young female client with bulimia nervosa has an unhealthy diet. An older adult client on a fixed income may not have the funds to eat a healthy diet. A client with Crohn's disease has a malabsorption syndrome. A client who resides in a nursing home has prepared meals as well as available supplements if required. A client who is a vegetarian is still able to receive ample iron supplementation in the vegetables being eaten.
16. The nurse is sending a client to be fitted for a compression garment for the treatment of lymphedema after having a mastectomy and node dissection. What does the nurse inform the client that will do to decrease the edema? Select all that apply. A) Increases local tissue pressure B) If worn for 30 days continuously, will permanently reduce the edema C) Decreases the stretching of the skin D) Helps muscles to propel lymphatic drainage E) Prevents tissue refilling with an excess volume of lymph
Ans: A, C, D, E Feedback: A compression garment, which consists of multiple layers of elastic material with proximal to distal compression gradation, increases local tissue pressure, decreases stretching of the skin, assists muscles to propel lymphatic drainage, and prevents tissue refilling with an excess volume of lymph. Because the lymph nodes have been removed, the condition will not be able to be permanently reduced by using the garment.
30. The nurse is caring for a client in the hospital who is being treated for Hodgkin's disease and is taking a chemotherapeutic regimen in the hospital's oncology unit. When reviewing the client's medication history, what regimen does the nurse recognize as the drugs in the treatment of Hodgkin's disease? A) Rocephin, Lasix, rifampin B) Cisplatin, cytarabine, prednisone C) Infliximab (Remicade) D) Enalapril (Lisinopril), Lopressor (Atenolol)
Ans: B Feedback: Cisplatin, cytarabine, prednisone are known as ICE for the chemotherapeutic treatment of Hodgkin's disease. There are several different regimens that may be used but the medications in options A, C, and D are not used for the treatment of Hodgkin's disease.
14. The nurse is caring for a client with lymphedema of the left arm in the clinic. The nurse measures a circumference of the affected extremity 4 cm larger in circumference than the opposite limb, and the client complains of feeling a heaviness and pain. There is limited movement of the left arm. What would the nurse grade and document this lymphedema as? A) Grade I (Mild) B) Grade II (Moderate) C) Grade III (Severe) D) Grade IV (Grossly edematous)
Ans: B Feedback: Grade II (Moderate), the circumference of affected limb is 4 cm, but not more than 8 cm larger than the unaffected limb; client experiences symptoms such as heaviness in the limb, pain, and limited movement. In Grade I (Mild), the circumference of the affected limb is 2 cm, but not more than 4 cm larger than the unaffected limb; the client is asymptomatic. In Grade III (Severe), the circumference of the affected limb is 8 cm greater than the unaffected limb, involves the entire limb, or is accompanied by infection or cellulitis.
9. A 16-year-old male client is in the burn unit following a motor vehicle accident. The nurse notes nonpitting edema in the client's left calf. What would the nurse document about this finding? A) 3+ edema of the left calf B) Secondary edema of the left calf C) Nonpitting primary edema of the left calf D) Primary edema of the left calf
Ans: B Feedback: Secondary lymphedema develops (1) as a complication of other disorders, such as repeated bouts of phlebitis and streptococcal infection, burns, or insect bites; or (2) as a consequence of treatment, such as the removal of multiple lymph nodes at the time of a mastectomy. Lymphedema following a burn injury is not primary lymphedema as in choice C or D, and it is not pitting edema as in choice A.
28. A client with Hodgkin's disease has a weight loss of 10% of body weight 6 months prior to the diagnosis, fever of 101° F, and drenching night sweats. What subclassification of Hodgkin's disease does this client fit into? A) A B) B C) C D) E
Ans: B Feedback: Stages I, II, III, and IV of adult Hodgkin's disease are subclassified into A and B categories: B for those with defined general symptoms and A for those without B symptoms. The B designation is given to client with any of the following symptoms: unexplained loss of more than 10% of body weight in 6 months before diagnosis, unexplained fever with temperatures over 100.4° F, and drenching night sweats. There is no subclassification of C or D.
12. A client, age 22 years, comes to the clinic and informs the nurse that he began having swelling in his right arm. There has been no injury or precipitating occurrence that caused the swelling. The nurse observes nonpitting edema from the upper arm to the fingertips. What action should the nurse initially perform? A) Instruct the client to elevate the extremity. B) Inspect and measure the arm. C) Apply a compression stocking. D) Administer a diuretic.
Ans: B Feedback: The nurse inspects and measures the affected area to assess the extent of enlargement and the condition of the skin initially. After collected the data, the nurse may instruct the client to elevate the arm and obtain the correct size for a compression stocking. Diuretic use is not an appropriate intervention at this time and would not be administered without a physician's order.
6. The nurse is caring for a client diagnosed with infectious mononucleosis who is having trouble eating. What would the nurse advise this client to improve his oral intake? A) Eat warm food and drink warm liquids. B) Eat soft, bland foods and drink cool liquids. C) Avoid spicy foods and drink warm liquids. D) Eat soft, bland foods and drink warm liquids.
Ans: B Feedback: The nurse inspects the client's throat for the extent of inflammation or edema. He or she gently palpates the lymph nodes to detect swelling and encourages fluids. Soft, bland foods and cool liquids are best for clients with ulcerations of the oral mucosa. Warm food and liquids and spicy food are not recommended.
20. The nurse is caring for a client with lymphangitis of the right leg who is receiving treatment with a broad-spectrum antibiotic. The nurse is giving a bath and observes the right leg is larger than it was 2 hours ago and the client feels hot. What is the first action by the nurse? A) Place the leg below the level of the heart. B) Notify the physician. C) Place cool compresses on the extremity. D) Begin performing passive range of motion exercises.
Ans: B Feedback: The nurse notifies the physician if the affected area appears to enlarge, additional lymph nodes become involved, or body temperature remains elevated. In severe cases with persistent swelling, the nurse teaches the client how to apply an elastic sleeve or stocking. The leg should be elevated to reduce the edema. A warm compress may be applied to promote comfort and enhance circulation. Passive range of motion would be contraindicated at this time.
24. The nurse is caring for the client with infectious mononucleosis that has inflammation of the pharyngeal mucosa. What foods or liquids would be best to offer to this client? A) A hot cup of milk B) Vanilla pudding and iced tea C) Tomato soup and hot herbal tea D) Beef and broccoli stir fry and a soft drink
Ans: B Feedback: Vanilla pudding and ice tea would be appropriate food for the nurse to offer. Soft, bland foods; cool liquids; and gargling with warm salt water are best for clients with inflammation of the oral and pharyngeal mucosa. Hot milk, tomato soup, hot tea, and beef and broccoli stir fry would not help with the inflammation of the pharynx.
22. The nurse is caring for a group of clients. Which client does the nurse suspect is most likely to have mononucleosis? A) A 46-year-old male who is complaining of chest pain and weakness B) A 19-year-old college student with cervical node enlargement and fever C) A 28-year-old female with lower abdominal discomfort and vaginal discharge D) A 30-year-old male client with a cough, chest discomfort, and fever
Ans: B Feedback: The virus most commonly affects young adults, especially those in close living quarters, such as armed services housing and college dormitories. Fatigue, fever, sore throat, headache, and cervical lymph node enlargement typically occur. The tonsils ooze white or greenish-gray exudates. Pharyngeal swelling can compromise swallowing and breathing. Some clients develop a faint red rash on their hands or abdomen. The liver and spleen become enlarged. The other clients with presenting symptoms do not correlate with the symptoms of mononucleosis.
The nursing instructor is talking with her clinical group about coagulopathies. How should the instructor define coagulopathies? A) Coagulopathies are bleeding disorders that are characterized by abnormalities in the numbers and types of red blood cells in the body. B) Coagulopathies are bleeding disorders that involve platelets or clotting factors. C) Coagulopathies are bleeding disorders that are characterized by a deficiency of globulins in the plasma. D) Coagulopathies are bleeding disorders that involve the destruction of stem cells in the bone marrow.
Ans: B Feedback: Coagulopathies are bleeding disorders that involve platelets or clotting factors. Coagulopathies do not involve the numbers and types of red blood cells. They are not characterized by a deficiency of globulins in the plasma, and they do not involve the destruction of stem cells in the bone marrow.
A client is being treated in the hospital for hypovolemia related to a bleeding peptic ulcer. The nurse obtains a blood pressure reading of 88/62 mm Hg, heart rate of 112 beats/minute, and a respiratory rate of 24 breaths/minute. What is the first action by the nurse? A) Administer blood. B) Notify the physician. C) Insert two large-bore intravenous catheters. D) Administer a colloid solution.
Ans: B Feedback:A systolic blood pressure below 90 mm Hg and heart rate above 100 beats/minute should be reported immediately. Administering blood, inserting two large-bore IV catheters, and administration of a colloid solution should be performed only with a physician's order and may not be required at this time.
A client with a diagnosis of pernicious anemia comes to the clinic complaining of numbness and tingling in his arms and legs. What do these symptoms indicate? A) Loss of vibratory and position senses B) Neurologic involvement C) Severity of the disease D) Insufficient intake of dietary nutrients
Ans: B Feedback:In clients with pernicious anemia, numbness and tingling in the arms and legs and ataxia are the most common signs of neurologic involvement. Some affected clients lose vibratory and position senses. Jaundice, irritability, confusion, and depression are present when the disease is severe. Insufficient intake of dietary nutrients is not indicated by these symptoms.
The nurse is instructing the client with sickle cell disease about the use of an inhaled vasodilator that may reduce sickling. What medication is the nurse instructing the client about? A) Nitrous oxide B) Nitric oxide C) Betamethasone D) Terbutaline (Brethine)
Ans: B Feedback:Inhaled nitric oxide—not nitrous oxide (laughing gas), a vasodilating agent—is believed to reduce sickling by promoting the binding of oxygen to hemoglobin. It is being used in the form of handheld inhalers to abort or relieve pain experienced during sickle cell crises. Betamethasone is a corticosteroid, and terbutaline is not used as an inhaler.
The nurse is caring for an older adult client with hemolytic anemia. What does the nurse understand about the reason this client is most susceptible to this disorder? A) The client is older and is probably noncompliant with medications. B) Older adult clients often take more medications than younger people. C) Older adult clients have more incidences of coagulation disorders. D) The older adult client does not follow up with physician appointments.
Ans: B Feedback:Older adults are particularly susceptible to drug-induced hemolytic anemia because they often take more drugs than younger people. Discontinuing the offending drug usually corrects the anemia. The assumption that because a client is older and probably noncompliant is incorrect. Older clients are more susceptible to gastrointestinal and genitourinary bleeding but not coagulation disorders. The older adult client does not lack follow-up with physicians more than other populations.
The nurse is caring for four clients on the medical-surgical unit of the hospital. What client is mostly likely to be receiving treatment for sickle cell crisis? A) A 29-year-old Caucasian female B) A 19-year-old African American male C) A 24-year-old Native American female D) A 36-year-old Eastern European female
Ans: B Feedback:Sickle cell disease is a common genetic disorder found primarily in African Americans but also in people from Mediterranean and Middle Eastern countries. It is unlikely that a Caucasian female, Native American female, or eastern European female will be affected by this disease.
You are caring for a client with multiple myeloma. Why would it be important to assess this client for fractures? A) Osteopathic tumors destroy bone causing fractures. B) Osteoclasts break down bone cells so pathologic fractures occur. C) Osteolytic activating factor weakens bones producing fractures. D) Osteosarcomas form producing pathologic fractures.
Ans: B Feedback:The abnormal plasma cells proliferate in the bone marrow, where they release osteoclast-activating factor. This, in turn, causes osteoclasts to break down bone cells, resulting in increased blood calcium and pathologic fractures. The plasma cells also form single or multiple osteolytic (bone-destroying) tumors that produce a "punched-out" or "honeycombed" appearance in bones such as the spine, ribs, skull, pelvis, femurs, clavicles, and scapulae. Weakened vertebrae lead to compression of the spine accompanied by significant pain. Options A, C, and D are distractors for this question.
The nurse is assigned to care for a client with polycythemia vera. When the nurse encourages the client to drink 3 L of fluid per day, the client states, "Why do I have to drink so much?" What is the best response by the nurse? A) "We don't want you to get dehydrated." B) "It helps adequately hydrate you and ensures a sufficient urine production." C) "It will help your heart beat regularly and effectively." D) "It will help restrict blood circulation."
Ans: B Feedback:The client should be advised to drink 3 quarts (or liters) per day. Adequate hydration promotes venous return and ensures sufficient urine production. Informing the client that the healthcare team does not want them to get dehydrated does not address the rationale that the client requires. Fluid hydration will not help the heart beat regularly or more effectively and it will not help to restrict blood circulation.
A client is found to have a low hemoglobin and hematocrit when laboratory work was performed. What does the nurse understand the anemia may have resulted from? Select all that apply. A) Infection B) Blood loss C) Abnormal erythrocyte production D) Destruction of normally formed red blood cells E) Inadequate formed white blood cells
Ans: B, C, D Feedback:Most anemias result from (1) blood loss, (2) inadequate or abnormal erythrocyte production, or (3) destruction of normally formed red blood cells. The most common types include hypovolemic anemia, iron-deficiency anemia, pernicious anemia, folic acid deficiency anemia, sickle cell anemia, and hemolytic anemias. Although each form of anemia has unique manifestations, all share a common core of symptoms. Anemia does not result from infection or inadequate formed white blood cells.
You are caring for an 87-year-old female who has been admitted to your unit with anemia. What would you suspect? A) Excessive consumption of coffee or tea B) Elimination of iron by the body C) Decrease in the total body iron stores with age D) Blood loss from the gastrointestinal or genitourinary tract
Ans: D Feedback:If an older adult is anemic, blood loss from the gastrointestinal or genitourinary tract is suspected. This is because iron-deficiency anemia is unusual in older adults as the body does not eliminate excessive iron, causing total body iron stores to increase with age. Excessive consumption of coffee or tea is not a causative factor for anemia in older adults.
10. You are caring for a client newly admitted to the unit with a diagnosis of lymphangitis. What interventions would you institute to help promote the resolution of the lymphangitis? Select all that apply. A) Apply ice to the area. B) Note the response to antibiotic therapy. C) Encourage independent activities of daily living. D) Elevate the area. E) Apply warm soaks/compresses to the area.
Ans: B, C, D, E Feedback: The nurse inspects the area two to three times daily and notes the client's response to antibiotic therapy. He or she gives assistance if the discomfort interferes with activities of daily living. Elevation reduces the swelling. Warmth promotes comfort and enhances circulation. The nurse notifies the physician if the affected area appears to enlarge, additional lymph nodes become involved, or body temperature remains elevated. In severe cases with persistent swelling, the nurse teaches the client how to apply an elastic sleeve or stocking.
17. A client with lymphedema of the left leg has a nursing diagnosis of Disturbed Body Image related to lymphedema of the left leg as evidenced by the statement, "I look terrible and am embarrassed to go out." What intervention can the nurse provide to help this client? A) Inform the client it is acceptable to stay away from social activities. B) Encourage the client to go out and socialize even if he doesn't want to. C) Suggest certain styles of clothing that conceal the enlargement of the leg. D) Refer the client to a psychiatrist.
Ans: C Feedback: Extensive emotional support is necessary when the edema is severe. The client's self-esteem often is decreased, which can lead to social withdrawal. The nurse supports the client's self-image by suggesting certain styles of clothing that conceal abnormal enlargement of an arm or leg. Informing the client to stay away from social activities can create a depressed mood and loneliness. The client should not be encouraged to go out and socialize if he is not ready nor referred to a psychiatrist at this point.
34. The nurse is collecting objective data from the client with lymphedema of the left leg. The nurse observes that the affected leg is 10 cm greater in measurement than the unaffected leg. The affected leg is hot to the touch and red. What classification of lymphedema does the nurse recognize this client has? A) Grade I (Mild) B) Grade II (Moderate) C) Grade III (Severe) D) Grade IV (Extreme)
Ans: C Feedback: In severe, the circumference of the affected limb is 8 cm greater than the unaffected limb, involves the entire limb, or is accompanied by infection or cellulitis (inflammation of connective tissue in or close to the skin). Mild is the circumference of the limb is 2 cm, but not more than 4 cm larger than the unaffected limb; client is asymptomatic. Moderate lymphedema is the circumference of the affected limb is 4 cm, but not more than 8 cm larger than the unaffected limb; client experiences symptoms such as heaviness in the limb, pain, and limited movement. There is no classification considered extreme.
32. A client with non-Hodgkin's lymphoma is receiving chemotherapy for treatment. The client is complaining of nausea during treatment. To maintain fluid intake, what type of food or fluid could the nurse offer the client? A) Milk B) Pudding C) Popsicle D) Chicken
Ans: C Feedback: Offer clear liquids such as carbonated beverages and water, ice pops, and flavored gelatin until nausea subsides. Thereafter, small, frequent, low-fat meals help prevent nausea, improve nutritional intake, and reduce weight loss. Milk, pudding, and chicken are too heavy when clients are experiencing nausea and may be given after the nausea subsides.
21. An adolescent client diagnosed with infectious mononucleosis asks the nurse if he will keep getting the disease. What is the best response by the nurse? A) "After having the disease, the virus dissipates and is gone forever." B) "Once you get the virus, it will infect you when your immune system is compromised." C) "One episode produces immunity, but the virus remains for a lifetime." D) "Once you have the symptoms of the virus, it will go away within a week and there will be no further episodes."
Ans: C Feedback: One episode of infectious mononucleosis produces subsequent immunity; however, the virus remains in the body for the person's lifetime. The virus does not dissipate and go away. If you have an incidence of infection, you are immune from further infections of Epstein-Barr virus. The symptoms do not generally go away for 2 to 6 weeks
8. A young client has just been diagnosed with lymphoma. The client asks you what a lymphoma is. What would be your best answer? A) It is a group of cancers that affect the body. B) It is a group of cancers connected to the hematopoietic system. C) It is a group of cancers that affect the lymphatic system. D) It is a group of cancers connected to the cardiovascular system.
Ans: C Feedback: The term lymphoma applies to a group of cancers that affect the lymphatic system. Option A is correct in part, but choice C is more specific. Lymphomas are not related to the hematopoietic or cardiovascular systems.
25. A client calls the clinic and informs the nurse that her boyfriend was diagnosed with infectious mononucleosis and wonders how long it would be before she got it. What does the nurse inform the client that the incubation period is for infectious mononucleosis? A) 3 days B) 7 to 10 days C) 30 to 50 days D) 50 to 70 days
Ans: C The incubation period for infectious mononucleosis is 30 to 50 days. The other answers are incorrect.
The LPN is following a plan of care for a client who is being treated for hypovolemic anemia and is at risk for hypovolemic shock. The nurse assesses vital signs and O2 saturation and observes the saturation at 89% for 3 minutes. What should the first action by the nurse be? A) Notify the charge nurse. B) Prepare to assist with intubation. C) Give oxygen per nasal cannula D) Place the client in the supine position.
Ans: C Feedback:An expected outcome for the client with hypovolemic anemia is to monitor to detect hypoxemia and manage and minimize inadequate oxygenation. The oxygen saturation should be monitored to measure the percentage of oxygen bound to hemoglobin. The nurse should report a sustained oxygen saturation value below 90%. Give oxygen per nasal cannula or simple mask to maintain oxygen saturation at or above 90%. It is important to administer the oxygen first and then contact the charge nurse to alert them. It is not necessary at this time if the client is not in respiratory distress to intubate the client. Placing the client in the supine position would decrease the oxygen saturation level further.
The nurse is instructing a client about taking a liquid iron preparation for the treatment of iron-deficiency anemia. What should the nurse include in the instructions? A) Do not take medication with orange juice because it will delay absorption of the iron. B) Iron may cause indigestion and should be taken with an antacid such as Mylanta. C) Dilute the liquid preparation with another liquid such as juice and drink with a straw. D) Discontinue the use of iron if your stool turns black.
Ans: C Feedback:Dilute liquid preparations of iron with another liquid such as juice and drink with a straw to avoid staining the teeth. Avoid taking iron simultaneously with an antacid, which interferes with iron absorption. Drink orange juice or take other forms of vitamin C with iron to promote its absorption. Expect iron to color stool dark green or black.
A client with sickle cell disease informs the nurse that he is having chest pain. The nurse hears the client coughing, wheezing, and breathing rapidly. What does the nurse suspect is occurring with this client? A) Vaso-occlusive crisis B) Pneumocystis pneumonia C) Acute chest syndrome D) Acute muscular strain
Ans: C Feedback:One of the unique manifestations of sickle cell disease is "acute chest syndrome," a type of pneumonia triggered by decreased hemoglobin and infiltrates in the lungs. Acute chest syndrome is characterized by respiratory symptoms, such as coughing, wheezing, tachypnea, and chest pain. Vaso-occlusive crisis causes decrease in tissue perfusion and predisposes the client to pneumonia but is not the present problem with this client. Pneumocystis pneumonia is present in the client with HIV/AIDS or other immunocompromised clients. The client's symptoms do not correlate with a diagnosis of acute muscular strain.
You are assisting your client with multiple myeloma to ambulate. What is the most important nursing diagnosis to help prevent fractures in this client? A) Increased mobility B) Adequate hydration C) Safety D) Adequate nutrition
Ans: C Feedback:Safety is paramount because any injury, no matter how slight, can result in a fracture.
Parents arrive to the clinic with their 5-year-old child and inform the nurse the child has just been diagnosed with sickle cell disease. The parents ask the nurse how this could have happened and which one of them is the carrier. What is the best response by the nurse? A) "Most likely, the father is the carrier of the gene." B) "The trait is passed down through the mother." C) "The child must inherit two defective genes, one from each parent." D) "It is an acquired, not a hereditary disorder."
Ans: C Feedback:Sickle cell disease is a hereditary disorder. To manifest this disorder, a person must inherit two defective genes, one from each parent, in which case all the hemoglobin is inherently abnormal. If the person inherits only one gene, he or she carries sickle cell trait. The hemoglobin of those who have sickle cell trait is about 40% affected. The other distractors are incorrect due to these factors.
The nurse is caring for a client who is developing hypovolemic shock from a duodenal ulcer bleed. What is the first intervention the nurse can provide to facilitate blood flow to the brain? A) Prepare the client for an endoscopy. B) Administer a crystalloid solution. C) Place the client in a modified Trendelenburg position. D) Test the client for blood in the stool.
Ans: C Feedback:The first action by the nurse would be to place the client in a modified Trendelenburg position to facilitate blood flow to the brain. Administering a crystalloid solution and testing the client for blood in the stool may be later action but is not relevant in facilitating blood flow to the brain. Preparing the client for an endoscopy would be important after the physician obtains the informed consent but would not facilitate blood flow to the brain.
A client with multiple myeloma is complaining of severe pain when the nurse comes in to give a bath and change position. What is the priority intervention by the nurse? A) Inform the client that the position must be changed, and then you will give her pain medication and omit the bath. B) Inform the client that she will feel better after receiving a bath and clean sheets. C) Obtain the pain medication and delay the bath and position change until the medication reaches its peak. D) Inform the client that the bath and positioning is an important part of client care and will be done right after pain medication administration.
Ans: C Feedback:When pain is severe, the nurse delays position changes and bathing until an administered analgesic has reached its peak concentration level and the client is experiencing maximum pain relief. Pain medication should never be delayed to assist in the control of the level of pain. Pain will not be relieved by a bath and clean sheets, only analgesics at this point in the client's illness.
A client is suspected of having leukemia and is having a series of laboratory and diagnostic studies performed. What does the nurse recognize as the hallmark signs of leukemia? Select all that apply. A) Diarrhea B) Nausea and vomiting C) Frequent infections D) Fatigue from anemia E) Easy bruising
Ans: C, D, E Feedback:Infections, fatigue from anemia, and easy bruising are hallmarks of leukemia. At the onset of leukemia, particularly in acute lymphocytic leukemia (ALL), a fever is present, the spleen and lymph nodes enlarge, and internal or external bleeding develops. Diarrhea and nausea and vomiting are not the hallmark signs of leukemia and can be indicators in many illnesses and gastrointestinal disorders.
15. A client with lymphedema in the left arm has weeping from the skin and has a small 2-cm ulcer on the upper arm. What test does the nurse anticipate the client will be prepared for? A) X-ray of the left arm B) Ultrasound of the left arm C) CT scan D) Lymphangiography
Ans: D Feedback: Lymphangiography is a special examination in which an intravenous dye and radiography are used to detect lymph node involvement that reveals the degree and extend of blockage in the lymph system. An x-ray of the arm, ultrasound, or CT scan will not reveal the extent of blockage.
1. The family nurse practitioner is performing a physical assessment on a client with a suspected lymphatic disorder. What would be the nurse practitioner's primary assessment for all clients with lymphatic disorders? A) Fever and sore throat B) Painful joints C) Signs of leukopenia and thrombocytopenia D) Enlargement of the lymph glands
Ans: D Feedback: Most of the disorders related to the lymph glands cause an inflammation of the lymph nodes. As a result, the nurse should assess the extent of enlargement of the lymph glands in a client suspected of a lymphatic disorder. Fever and sore throat are the secondary signs and symptoms in such disorders. These clients do not complain of painful joints or exhibit signs of leukopenia and thrombocytopenia.
19. The nurse is obtaining objective data from a client with lymphangitis of the left arm. What does the nurse expect to find when collecting this data from the client? A) Pulsatile mass in the axilla B) Weeping and oozing of fluid from the arm C) Cold, clammy arm D) Red streaks following the course of the lymph channels
Ans: D Feedback: Red streaks follow the course of the lymph channels and extend up the arm or leg. Fever also may be present. When lymphadenitis is present, the lymph nodes along the lymphatic channels are enlarged and tender on palpation. Diagnosis is made by visual inspection and palpation. The nurse does not expect to find a pulsatile mass. Weeping and oozing would indicate lymphedema. The arm would be warm or hot, not cold and clammy.
29. A client with Hodgkin's disease has bilateral lymph nodes that are affected with extension through the spleen as well as affecting the bone marrow. What stage of the disease does the nurse recognize the client is in? A) I B) II C) III D) IV
Ans: D Feedback: Stage IV involves bilateral lymph nodes affected and extension includes spleen plus one or more of the following: bones, bone marrow, lungs, liver, skin, gastrointestinal structures, or other sites. Stage I is single lymph node region. Stage II is two or more lymph node regions on one side of the diaphragm. Stage III is lymph node regions on both sides of the diaphragm, but extension is limited to the spleen.
13. The nurse is on a mission trip to a third world country to provide nursing care to a large group of clients. A client asks the nurse to look at his leg that is grossly edematous compared to the other extremity. What does the nurse understand is the most common cause of this disorder known as elephantiasis? A) Reaction to an antibiotic B) Smallpox vaccination C) Lack of healthcare D) A parasitic worm
Ans: D Feedback: Worldwide, the most common cause of lymphedema is a parasitic worm; mosquitoes transmit the parasite, resulting in a condition known as elephantiasis.
Your client was admitted to the emergency department after an accident with a chain saw. The client is exhibiting signs and symptoms of acute hypovolemic anemia from severe blood loss. What signs and symptoms would you assess for? A) Malabsorption disorders B) Postural hypotension C) Fatigue D) Reduced urine output
Ans: D Feedback: Acute hypovolemic anemia from severe blood loss is evidenced by the signs and symptoms of hypovolemic shock, which include reduced urine output. The symptoms of chronic hypovolemic anemia include fatigue and postural hypotension. Clients with malabsorption disorders are at great risk of iron-deficiency anemia.
The nurse is instructing the client with polycythemia vera how to perform isometric exercises such as contracting and relaxing the quadriceps and gluteal muscle during periods of inactivity. What does the nurse understand is the rationale for this type of exercise? A) Isometric exercise programs are inclusive of all muscle groups and have an aerobic effect to increase the heart rate. B) Isometric exercise decreases the workload of the heart and restores oxygenated blood flow. C) This type of exercise increases arterial circulation as it returns to the heart. D) Contraction of skeletal muscle compresses the walls of veins and increases the circulation of venous blood as it returns to the heart.
Ans: D Feedback:Isometric exercise induce contraction of skeletal muscle so that it compresses the walls of veins and increases the circulation of venous blood as it returns to the heart. Isometric exercises do not have an aerobic effect and should not increase the heart rate; although, it may increase blood pressure. Isometric exercise does not decrease the workload of the heart. Arterial flow moves blood flow away from the heart after being oxygenated.
The nurse is collecting data for a patient who has been diagnosed with iron-deficiency anemia. What subjective findings does the nurse recognize as symptoms related to this type of anemia? A) "I feel hot all of the time." B) "I have a difficult time falling asleep at night." C) "I have an increase in my appetite." D) "I have difficulty breathing when walking 30 feet."
Ans: D Feedback:Most clients with iron-deficiency anemia have reduced energy, feel cold all the time, and experience fatigue and dyspnea with minor physical exertion. The heart rate usually is rapid even at rest. The CBC and hemoglobin, hematocrit, and serum iron levels are decreased. The client would feel cold and not hot. The client is fatigue and able to sleep often with a decrease in appetite, not an increase.
A client was admitted to the hospital with a pathologic pelvic fracture. The client informs the nurse that he has been having a strange pain in the pelvic area for a couple of weeks that was getting worse with activity prior to the fracture. What does the nurse suspect may be occurring based on these symptoms? A) Hemolytic anemia B) Polycythemia vera C) Leukemia D) Multiple myeloma
Ans: D Feedback:The first symptom usually is vague pain in the pelvis, spine, or ribs. As the disease progresses, the pain becomes more severe and localized. The pain intensifies with activity and is relieved by rest. When tumors replace bone marrow, pathologic fractures develop. Hemolytic anemia does not result in pathologic fractures nor does polycythemia vera or leukemia.
A client is seen in the emergency department with severe pain related to a sickle cell crisis. What does the nurse understand is occurring with this client? A) The client has a decreased tolerance of pain related to the chronic nature of the illness. B) Bone marrow decreases the erythrocyte production causing decrease in hypoxia. C) Over-hydration enlarges the red blood cells. D) Vascular occlusion in small vessels decreasing blood and oxygen to the tissues.
Ans: D Feedback:The person with sickle cell disease repeatedly suffers from two major problems: (1) episodes of sickle cell crisis from vascular occlusion, which develops rapidly under hypoxic conditions, and (2) chronic hemolytic anemia. During a sickle cell crisis, the sickle-shaped cells lodge in small blood vessels, where they block the flow of blood and oxygen to the affected tissue. The vascular occlusion induces severe pain in the ischemic tissue. The client may have increased tolerance for pain due to the chronic nature of the illness. Bone marrow increases the erythrocyte production. Underhydration increases the client's risk of developing a vaso-occlusive crisis.
The nurse is caring for a client with hypovolemic anemia who is now in hypovolemic shock. What indication does the nurse have that the client is having inadequate renal perfusion? A) Hematuria B) Blood pressure of 90/60 mm Hg C) Jaundice of the sclera D) Urine output of 15 mL/hour
Ans: D Feedback:Urine output of less than 30 to 50 mL/hour reflects inadequate renal perfusion. The kidneys must excrete 30 to 50 mL/hour or 500 mL/24 hours to eliminate wastes sufficiently. Hematuria is an indicatory of other problems such as hemorrhagic cystitis, trauma to the bladder, etc. It is not an indicator of renal perfusion. A blood pressure of 90/60 mm Hg does not indicate that the client is having a decrease in renal perfusion nor does jaundice. Jaundice is present when the liver starts to fail.
A client will be having a bone marrow aspiration to determine the status of blood cell formation. What role does the nurse have during the test? A) Inject the anesthetic so the client will have no sensation of pain. B) The nurse explains the procedure to the patient and obtains the informed consent. C) The nurse sets up the equipment for the physician and then must leave the room to allow for privacy. D) The nurse assists the physician and supports the client during the procedure.
Feedback: The nurse assists the physician, supports the client during the procedure, and monitors the client's status afterward. Injecting anesthetic agents is beyond the scope of practice for the nurse. The physician obtains informed consent for the procedure, and the nurse witnesses the signature. The nurse should not leave the room because the client requires monitoring during and after the procedure.