courseware chapter 31 lewis 1-33 NCLEX questions

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

A. A 47-year-old man who had a gastrectomy (removal of the stomach) There are many causes of cobalamin 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. Reference: 668

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

A. An African American man who has a diagnosis of sickle cell disease 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. Reference: 672

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.

A. Avoid dehydration. B. Avoid high altitudes. 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. Reference: 675

Which assessment findings are consistent with thrombocytopenia? A. Petechiae, ecchymoses B. Pallor, spider angiomas C. Cyanosis, dullness D. Jaundice, purpura

A. Petechiae, ecchymoses Many patients with thrombocytopenia are asymptomatic. The most common symptom is bleeding, usually mucosal or cutaneous. Mucosal bleeding may manifest as epistaxis and gingival bleeding, and large bullous hemorrhages may appear on the buccal mucosa because of the lack of vessel protection by the submucosal tissue. Bleeding into the skin manifests as petechiae, purpura, or superficial ecchymoses Reference: 679

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

A. Ready-to-eat cereal B. Wheat tortillas C. Lentils Whole-grain foods and beans are high in folic acid. Reference: 666, 670

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

A. Reduced RBCs, reduced white blood cells (WBCs), and reduced platelets Because all marrow elements are affected, hemoglobin, WBC, and platelet values are decreased in aplastic anemia. Other RBC indices usually are normal. Reference: 671

The Schilling test for pernicious anemia involves A. administration of radioactive cobalamin 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.

A. administration of radioactive cobalamin and measuring its excretion in the urine. Parietal cell function can be assssed with a Schilling test. After radioactive cobalamin 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. Reference: 669

When providing care for a patient with thrombocytopenia, you instruct the patient to A. dab his or her nose instead of blowing. B. be careful when shaving with a safety razor. C. continue with physical activities to stimulate thrombopoiesis. D. avoid aspirin because it may mask the fever that occurs with thrombocytopenia.

A. dab his or her nose instead of blowing. Blowing the nose forcefully should be avoided; the patient should gently pat it with a tissue if needed. Patients with thrombocytopenia should avoid aspirin; aspirin reduces platelet adhesiveness, contributing to bleeding. Patients should not perform vigorous exercise or lift weights. If the patient is weak and at risk for falling, supervise the patient when out of bed. Patients should be instructed not to shave with a blade; an electric razor should be used. Reference: 684

You encourage the patient with cobalamin deficiency to seek treatment because untreated pernicious anemia may result in A. death. B. liver failure. C. heart failure. D. gastrectomy.

A. death. Regardless of how much cobalamin 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 (see Table 31-5). Parenteral (cyanocobalamin or hydroxocobalamin) or intranasal (Nascobal, CaloMist) administration of cobalamin is the treatment of choice. Without cobalamin administration, these individuals will die in 1 to 3 years. Reference: 669

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.

A. dyspnea and tachycardia. 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. Reference: 662

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.

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. (all of the above) 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. Reference: 674-675

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.

A. monitoring stools for guaiac. B. instructions about a high-iron diet. 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). Reference: 666

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.

A. normocytic. B. normochromic. 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. Reference: 670

A complication of the hyperviscosity of polycythemia is A. thrombosis. B. cardiomyopathy. C. pulmonary edema. D. disseminated intravascular coagulation (DIC).

A. thrombosis. 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. Reference: 677

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

B. Brittle nails; smooth, shiny tongue; and cheilosis 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 deficiency. Tenting skin is a sign of dehydration that often accompanies diarrhea. Blue mucous membranes are associated with cyanosis. Reference: 666

Which finding allows you to identify the patient's anemia as folic acid deficiency rather than cobalamin deficiency? A. Loss of appetite B. Lack of neuromuscular symptoms C. Red tongue D. Change in nail shape

B. Lack of neuromuscular symptoms The absence of neurologic problems is an important diagnostic finding and differentiates folic acid deficiency from cobalamin deficiency. Reference: 669

The primary pathophysiology underlying thalassemia is A. erythropoietin deficiency. B. abnormal hemoglobin synthesis. C. autoimmunity. D. S-shaped hemoglobin.

B. abnormal hemoglobin synthesis. 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. Reference: 668

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.

B. assist with or perform phlebotomy at the bedside. 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. Reference: 678

The nursing student asks the clinical instructor to explain why clinical symptoms are more important than laboratory values when the patient has experienced blood loss. The instructor correctly recognizes that A. nurses should focus on clinical symptoms because those are the parameters of nursing practice. B. blood values are often normal or even high because fluid shifts have not occurred and laboratory values are falsely high. C. laboratory values are used to supplement nursing assessments. D. laboratory findings are often falsely low in the early period of blood loss.

B. blood values are often normal or even high because fluid shifts have not occurred and laboratory values are falsely high. It is essential to understand that the clinical signs and symptoms the patient is experiencing are more important than the laboratory values. For example, an adult with a bleeding peptic ulcer who had a 750-mL hematemesis (15% of a normal total blood volume) within the past 30 minutes may have postural hypotension but have normal hemoglobin and hematocrit values. Over the ensuing 36 to 48 hours, most of the blood volume deficit will be replaced by the movement of fluid from the extravascular into the intravascular space. Only at these later times will the hemoglobin and hematocrit values reflect the blood loss. Reference: 671

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 anemi

B. dietary intake of iron. Iron deficiency anemia is a type of microcytic, hypochromic anemia. Reference: 662

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.

B. fatigue. 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. Reference: 662

A patient with a diagnosis of hemophilia fell down an escalator earlier in the day and is now experiencing bleeding in her left knee joint. Your immediate response should include A. immediate transfusion of platelets. B. resting the patient's knee to prevent hemarthroses. C. assistance with intracapsular injection of corticosteroids. D. range-of-motion exercises to prevent thrombus formation.

B. resting the patient's knee to prevent hemarthroses. In patients with hemophilia, joint bleeding requires resting of the joint to prevent deformities from hemarthrosis. Clotting factors, not platelets or corticosteroids, are administered. Thrombus formation is not a central concern in a patient with hemophilia. Reference: 685-686

Which nursing intervention should you prioritize in the care of a 30-year-old woman who has a diagnosis of immune thrombocytopenic purpura (ITP)? A. Administration of packed red blood cells B. Administration of clotting factors VIII and IX C. Administration of oral or intravenous corticosteroids D. Maintenance of reverse isolation and application of standard precautions

C. Administration of oral or intravenous corticosteroids Common treatment modalities for ITP include corticosteroid therapy to suppress the phagocytic response of splenic macrophages. Blood transfusions, administration of clotting factors, and reverse isolation are not interventions that are indicated in the care of patients with ITP. Reference: 680

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

C. Hyperbilirubinemia As a result of accelerated RBC breakdown, the patient may have characteristic clinical findings of hemolysis, including jaundice and elevated serum bilirubin levels. Reference: 674

You expect which laboratory finding to be abnormal for a patient with hemochromatosis? A. RBCs B. Platelets C. Iron D. Folic acid

C. Iron The normal range for total body iron is 2 to 6 g. Individuals with hemochromatosis accumulate iron at a rate of 0.5 to 1.0 g each year and may exceed total iron concentrations of 50 g. The other values are near normal. Reference: 676

Which organ is at greatest risk due to the effects of hemolytic anemia? A. Heart B. Spleen C. Kidney D. Liver

C. Kidney 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 Reference: 672

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

C. Orange juice 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. Reference: 667

Which findings do you expect to find for a patient with acute loss of blood? A. Weakness, lethargy, and warm, dry skin B. Restlessness, hyperthermia, and bradycardia C. Tachycardia, hypotension, and cool, clammy skin D. Widened pulse pressure, anxiety, and hypoventilation

C. Tachycardia, hypotension, and cool, clammy skin Tachycardia, hypotension, and cool, clammy skin can be found in a person who has had an acute loss of blood. These are manifestations of hypovolemic shock. A person with a bleeding peptic ulcer who had a 750-mL hematemesis (15% of a normal total blood volume) within the past 30 minutes may have postural hypotension. Because blood is shunted to major organs, the skin in the periphery is cool to the touch. Tachycardia is the body's attempt to maintain adequate cardiac output. Reference: 671

You anticipate the patient with hemochromatosis to be from which ethnic group? A. African American B. Hispanic American C. White European D. Chinese

C. White European Hemochromatosis is the most common genetic disorder among whites, with an incidence of 3 to 5 cases per 1000 whites of European ancestry. Reference: 676

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.

C. age 2 year. The manifestations, including growth and developmental deficits, develop in childhood by 2 years of age. Reference: 668

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

D. Infection and hemorrhage 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. Reference: 671

Which sign or symptom would you recognize as a unique characteristic specific to hemolytic anemia? A. Tachycardia B. Weakness C. Decreased RBCs D. Jaundice

D. Jaundice 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. Reference: 672

You anticipate that a patient with von Willebrand's disease undergoing surgery will be treated with administration of von Willebrand factor (vWF) and A. thrombin. B. factor VI. C. factor VII. D. factor VIII.

D. factor VIII. Von Willebrand's disease involves a deficiency of the von Willebrand coagulation protein, variable factor VIII deficiencies, and platelet dysfunction. Treatment includes administration of vWF and factor VIII. Reference: 684