NP Cert Exam - Hematological and Select Immunological Disorders
1. Worldwide, which of the following is the most common type of anemia? A. pernicious anemia B. folate-deficiency anemia C. ACD D. IDA
1. Correct: D. IDA IDA (D) is the leading cause of anemia worldwide, most commonly caused by chronic, low-volume blood loss. Losses of only 2 to 3 mL per day can cause IDA, frequently by GI bleeding, repeated phlebotomy, or per- sistent excessive menstrual flow. Incorrect: ACD (C) is the second leading cause of anemia world- wide and can be attributed to acute and chronic inflammation (infection, arthritis), renal insufficiency, malignancy, and hypothyroidism. Pernicious anemia (A) and folate-deficiency anemia (B) are the most common causes of macrocytic anemia and are most frequently caused by inadequate dietary intake or a malabsorption syndrome.
10. A woman who is planning a pregnancy should increase her intake of which of the following to mini mize the risk of neural tube defect in the fetus? A. iron B. niacin C. folic acid D. vitamin C
10. Correct: C. folic acid Maternal folic acid deficiency is a teratogenic state that can increase the risk of neural tube defects (C). A woman planning a pregnancy should be advised to take an additional 0.4 mg or more per day of folic acid for 3 months prior to conception. Incorrect: Maternal folic acid deficiency can lead to fetal neural tube defects, and so supplementation of folic acid is recommended for women planning on pregnancy for at least 3 months prior to conception. For unplanned pregnancies or where prepregnancy counseling was not sought, folic acid supplementation during the first 7 weeks of pregnancy seems to offer some benefit in neural tube protection. Supplementation with iron (A), niacin (B), or vitamin C (D) will not impact the risk of neural tube defect during pregnancy.
48. Increased risks for fatal reactions from anaphylaxis include all of the tollowing except: A. personal history of asthma. B. delay in administering epinephrine. C. age in the teen years. D. delay in administering antihistamines.
48.Correct: D. delay in administering antihistamines. Severe anaphylaxis can be a life-threatening event and should be treated with parenteral epinephrine to reduce mortality risk. Antihistamines are considered second-line treatment but should not replace the use of epinephrine. A delay in the use of antihistamines is not associated with improved mortality (D). Incorrect: Risk factors for fatal anaphylaxis include being a teen or young adult (C), having asthma (A), and failure to administer epinephrine in a timely manner (B).
11. Risk factors for folate-deficiency anemia include: A. menorrhagia. B. chronic ingestion of overcooked foods. C. use of NSAIDs. D. gastric atrophy.
11. Correct: B. chronic ingestion of overcooked foods. Folic acid is a water-soluble B complex vitamin that is found in abundance in peanuts, fruits, and vegetables, as well as folic acid-supplemented foods, such as most flours. However, overheating and overcooking foods rich in folic acid will destroy the vitamin and contribute to folate-deficiency anemia (B). Incorrect: The most common causes of folate-deficiency ane- mia include inadequate dietary intake of folate and a decreased ability to absorb folate, such as with malab- sorption syndromes (e.g., sprue, celiac disease). Men- orrhagia (A) would be a risk factor for IDA through chronic low-volume blood loss. Gastric atrophy (D) or the use of NSAIDs (C) are not associated with folate- deficiency anemia.
12. Folate-deficiency anemia causes which of the following changes in the BC indices? A. microcytic, normochromic B. normocytic, normochromic C. microcytic, hypochromic D. macrocytic, normochromic
12. Correct D, macrocytie, normochromie Folate-deficiency anemia is characterized as a macro cytic, normochromic anemia according to Wintrobes clansification. In this anemia, Hgb production is unaf lected as iron levels are normal. However, folate defi ciency impairs DNA synthesis within RBCs and causes distinct changes, including macrocytosis, Incorrect: Mierocytie and/or hypochromic anemias (A, B, C) typically result from decreased Hgb production, often related to iron deficiency. This is not the case with folate-deficiency anemia, where Hgb production is nor- mal. Macrocytosis occurs in folate-deficiency anemia as the micronutrient deficiency impairs DNA synthesis in RBCs within the bone marrow.
13. Pernicious anemia is usually caused by: A. dietary deficiency of vitamin B g B. lack of production of intrinsic factor by the gastric mucosa. C. RBC enzyme deficiency. D. a combination of micronutrient deficiencies caused by malabsorption.
13. Correct: B. lack of production of intrinsic factor by the gastric mucosa. Pernicious anemia is not a result of dietary deficien- cies but is related to the inability to absorb vitamin B,2 that is found abundantly in foods. When vitamin B, is ingested, it must bind with intrinsic factor for intestinal absorption. Failure to produce intrinsic factor by the gastric parietal cells can lead to vitamin B, deficiency and pernicious anemia. Incorrect: Dietary deficiency is an uncommon cause of pernicious anemia, as vitamin B, is abundantly found in a variety of foods (A). Pernicious anemia specifically relates to deficiency in vitamin B, due to malabsorption caused by a lack of intrinsic factor production, thus not a com- bination of micronutrient deficiencies (D). Intrinsic factor is produced by gastric parietal cells and does not involve an enzyme from RBCs (C).
14. Pernicious anemia causes which of the following changes in the RBC indices? A. microcytic, normochromic B. normocytic, normochromic C. microcytic, hypochromic D. macrocytic, normochromic
14. Correct: D. macrocytic, normochromic Similar to folate-deficiency anemia, pernicious anemia is characterized as a macrocytic, normochromic ane- mia (D) according to Wintrobe's classification. In this anemia, Hgb production is unaffected as iron levels are normal. However, vitamin B, deficiency impairs DNA synthesis within RBCs and causes distinct changes within the bone marrow, including macrocytosis. Incorrect: Microcytic and/or hypochromic anemias (A, B, C) typically result from decreased Hgb production, often related to iron deficiency. This is not the case with pernicious anemia, where Hgb production is normal. Macrocytosis occurs with vitamin B, deficiency as the micronutrient deficiency impairs DNA synthesis in RBCs within the bone marrow.
15. Common physical examination findings in patients with pernicious anemia include: A. hypoactive bowel sounds. B. stocking-glove neuropathy. C. thin, spoon-shaped nails. D. retinal hemorrhages.
15. Correct: B. stocking-glove neuropathy. Vitamin By is an important micronutrient needed for proper neurological function in the body. Pernicious anemia, often caused by malabsorption of vitamin B, is associated with neurological symptoms that can include stocking-glove neuropathy (B), confusion, short-term memory loss, poor balance, irritability, and in severe cases, hallucinations and delusions. Incorrect: Pernicious anemia is associated with neurological signs and symptoms. Hypoactive bowel sounds (A), thin, spoon-shaped nails (C; often seen in IDA), and retinal hemorrhages (D; often observed in poorly controlled hypertension) are not specific to pernicious anemia.
16. You examine a 47-year-old man who presents with difficulty initiating and maintaining sleep and chronic pharyngeal erythema with the following results on hemogram: Hgb = 15 g/dL. (normal 14 to 16 g/dL) Hct = 45% (normal 42% to 48%) RBC = 4.8 million mm' (normal 4.7 to 6.1 million mm') MCV = 108 fL (normal 81 to 96 fL) MCHC = 33.2 g/dL. (normal 31 to 37 g/dL) These values are most consistent with: A. pernicious anemia. B. alcohol abuse. C. thalassemia minor. D. Fanconi anemia.
16. Correct: B. alcohol abuse. Alcohol abuse can result in mild macrocytosis without anemia, as found in this patient. Usually the individual will have other findings consistent with heavy alcohol use, such as pharyngeal redness and sleep disturbance. Incorrect: This patient has a normal Hgb level and so does not present with pernicious anemia (A). Thalassemias are associated with a microcytic anemia according to Win- trobe's classification, while this patient demonstrates mild macrocytosis (C). Fanconi anemia is a rare, genet- ically linked disease that affects the bone marrow and results in reduced production of all types of blood cells, and so can be ruled out for this patient who has normal RBC production (D).
21. When prescribing erythropoietin supplementation, the nurse practitioner (NP) considers that: A. the adrenal glands are its endogenous source. B. the addition of micronutrient supplementation needed for erythropoiesis is advisable. C. its use is as an adjunct in treating thrombocytopenia. D. with its use, the RBC life span is prolonged.
21. Correct: B. the addition of micronutrient supplemen- tation needed for erythropoiesis is advisable. Erythropoietin is a hormone primarily produced in the kidneys that stimulates the production of RBCs in bone marrow. Recombinant human erythropoietin is often used to treat anemia associated with certain diseases, such as end-stage renal disease, HIV infection, and cancer chemotherapy. In anticipation of reticulocytosis, micronutrient supplementation is recommended, such as iron supplementation. Incorrect: Endogenous erythropoietin is predominantly produced in the kidneys, not the adrenal glands (A). It is used to stimulate production of RBs, not platelets that are lacking in thrombocytopenia (C). Erythropoietin will not have any impact on the life span of RBCs, which is typically 90 to 120 days.
17. You examine a 22-year-old woman of Asian ancestry. She has no presenting complaint. Hemogram results are as follows: Hgb = 9.1 g/dL. (normal 12 to 14 g/dL.) Hct = 28% (normal 36% to 43%) RBC = 5.6 million mm' (normal 4.2 to 5.4 million mm3) MCV = 68 fL (normal 81 to 96 fL) MCHC = 33.2 g/dL (normal 31 to 37 g/dI) RDW = 13% (normal <15%) Reticulocytes = 1.5% (normal 1% to 2%) This is most consistent with the laboratory assessment of: A. IDA. B. Cooley anemia. C. Alpha-thalassemia minor. D. Hgb Barts.
17. Correct: C. Alpha-thalassemia minor. Asian and African ethnicities are at risk for -thalassemia minor, which is characterized by micro- cytic RBCs, normal RDW, and an elevated number of RBCs. Among the answer choices, the diagnostic find- ings were most consistent with -thalassemia minor (C). Incorrect: IDA (A) is characterized by microcytic cells and elevated RDW. Cooley's anemia (B), also known as ß-thalassemia major, is a severe, life-threatening condition where two defective genes are inherited, leading to a com- plete lack of beta protein in Hgb. Hgb Barts is found in fetal cord blood and in newborns in association with alpha-thalassemia (D) but would not be present in a 22-year-old woman.
18. A 68-year-old man who is usually healthy presents with new onset of "huffing and puffing" with exer- cise for the past 3 weeks. Physical examination reveals conjunctiva pallor and a hemic murmur. Hemogram results are as follows: Hgb = 7.6 g/dL Hct = 20.5% RBC = 2.1 million mm3 MCV = 76 fL MCHC = 28 g/dL RDW = 18.4% Reticulocytes = 1.8% The most likely cause of these findings is: A. poor nutrition. B. occult blood loss. C. malabsorption. D. chronic inflammation.
18. Correct: B. occult blood loss. A microcytic, hypochromic anemia with elevated RDW is most consistent with IDA. A common cause of IDA is chronic, low-volume blood loss (B). Incorrect: Poor nutrition (A) and malabsorption (C) are more con- sistent with the macrocytic anemias of folate-deficiency anemia and pernicious anemia, respectively. Chronic inflammation can cause ACD, which is characterized as a normocytic, normochromic anemia (D).
19. You examine a 57-year-old woman with rheumatoid arthritis who is on a biological disease-modifying antirheumatic drug (DMARD) but continues to have poor disease control, and you find the following results on hemogram: Hgb = 10.5 g/dL Hct = 33% RBC = 3.1 million mm3 MCV = 88 fL MCHC = 32.8 g/dL RDW = 12.2% Reticulocytes = 0.8% The laboratory findings are most consistent with: A. pernicious anemia. B. ACD. C. Beta-thalassemia minor. D. folate-deficiency anemia.
19. Correct: B. ACD. When making a differential diagnosis, it is important to consider all patient factors. The presence of a normo- cytic (as per Wintrobe's classification), normochromic anemia would suggest ACD. This is consistent with the presence of a chronic inflammatory condition that is not well controlled with medication. Reticulocytopenia also suggests a poor hematological response related to a chronic condition. Incorrect: As per Wintrobes classification, pernicious anemia (A) and folate-deficiency anemia (D) are macrocytic ane- mias with elevated RDWs that would not be consistent with this patient. -Thalassemia minor (C) results in a microcytic, normochromic anemia with an elevated number of RBCs.
2. Most of the body's iron is obtained from: A. animal-based food sources. B. recycled iron content from aged RBCs. C. endoplasmic reticulum production. D. vegetable-based food sources.
2. Correct: B. recycled iron content from aged RBCs. The body's most important source of iron is the recy. cled iron content from aged RBCs. Because of this, chronic, low-volume blood loss is the leading cause of IDA as the body is unable to adequately replace this lost iron. Incorrect: A well-balanced diet can be an important source of iron. However, in developed countries, diet (A, D) is rarely an etiology for IDA as recycled iron from aged RBCs is the major source of the body's iron. An estimated 8 years of poor iron intake are needed in adults before IDA occurs. Iron is not produced in the endoplasmic reticulum (C).
20. You examine a 27-year-old woman with menorrhagia who is otherwise well and note the following results on hemogram: Hgb = 10.1 g/dl Hct = 32% RBC = 2.9 million mm3 MCV = 72 fl MCHC = 28.2 g/dL RDW = 18.9% Physical examination is likely to include: A. conjunctiva pallor. B. hemic murmur. C. tachycardia. D. no specific anemia-related findings.
20. Correct: D. no specific anemia-related findings. Anemia in a patient with menorrhagia is likely due to IDA from chronic low-volume blood loss. However, in mild anemia, symptoms may not be evident, and physical examination usually contributes little to the diagnosis. Incorrect: Mild cases of anemia will not typically present with obvious signs and symptoms. During more severe cases, such as when Hgb is below 8 g/dL, individuals may present with obvious signs and symptoms, such as pale conjunctiva (A) or a hemic murmur (B). In elderly patients and those with coronary artery disease, symptoms of anemia can include signs of heart failure, such as distended neck veins, rales, tachycardia (C), and hepatomegaly.
22. In the first weeks of anemia therapy with parenteral vitamin B12 in a 68-year-old woman with hypertension who is taking a thiazide diuretic, the patient should be carefully monitored for: A. hypernatremia. B. dehydration. C. hypokalemia. D. acidemia.
22. Correct: C. hypokalemia. Hypokalemia is common during peak times of reticu- locytosis, such as during the first week of vitamin B12 therapy in severe anemia. Patients should be monitored daily for hypokalemia, particularly in those with addi- tional risk factors for hypokalemia, such as those taking a diuretic or digoxin. Incorrect: Hypokalemia is a common finding during intense retic- ulocytosis, particularly in those being treated for severe anemia and who have additional risk factors for hypo- kalemia. Hypernatremia (A) and acidemia (D) are not associated with vitamin B, therapy and reticulocytosis or the use of a diuretic. Though it is important to ensure the patient is adequately hydrated, careful monitoring for dehydration is not needed for a patient who can tol- erate fluids (B).
23. Which of the following conditions is unlikely to result in ACD? A. rheumatoid arthritis B. peripheral vascular disease C. chronic renal insufficiency D. osteomyelitis
23. Correct: B. peripheral vascular disease ACD is associated with a number of chronic health conditions, including renal disease, inflammation, and infection. Peripheral vascular disease (B) is not typically associated with ACD. Incorrect: ACD is caused by reduced erythropoietin response in the marrow. Select chronic conditions include chronic inflammation (rheumatoid arthritis [A]) and infection (HIV, osteomyelitis [D]). Chronic renal insufficiency (C) is also a major contributor to ACD as this can lead to decreased production of endogenous erythropoietin that stimulates reticulocytosis.
24. In health, the ratio of Hgb to Hct is usually: A. 1:1. B. 1:2. C. 1:3. D. 1:4.
24. Correct: C. 1:3. The normal Hgb-to-Hct ratio is 1:3. Thus, an Hgb level of 12 g/dL should correspond with an Hct of 36%. Incorrect: The normal Hgb-to-Hct ratio is 1:3. The ratio can differ during periods of severe dehydration, where the Hct is elevated (e.g., Hgb of 12 g/dL and Hct of 39%), or during periods of overhydration, where Hct is decreased (Hgb of 12 g/dL and Hct of 32%).
25 to 28. Match each definition with the correct term. 25. RBCs of unequal size 26. Variation in BC shape 27. Increase in the production of immature RBCs 28. Abnormal decrease in the production of immature RBCs A. poikilocytosis B. anisocytosis C. reticulocytosis D. reticulocytopenia
25. Correct: B. anisocytosis Anisocytosis, where blood cells are of unequal size, is commonly found in certain anemias, particularly IDA. 26. Correct: A. poikilocytosis Poikilocytosis is characterized by RBCs of varying shapes. These can include oval, teardrop, sickle shaped, or irregularly contracted. Genetic causes can include sickle cell anemia and thalassemia, while acquired causes can include IDA, megaloblastic anemia, and auto- immune hemolytic anemias. 27. Correct: C. reticulocytosis Reticulocytosis is the increased production of new RBCs (reticulocytes). This is typically the body's normal response to correct anemia. The normal percentage of circulating reticulocytes is 1% to 2%, while this percent- age will be higher in reticulocytosis. 28.Correct: D. reticulocytopenia Reticulocytopenia is an abnormally low percentage of circulating reticulocytes and is a possible sign of inade- quate hemopoiesis.
29. Which of the following is not consistent with ACD? A. Normal limit (NL) RDW B. NL MCHC C. Hct less than 24% D. NL to slightly elevated serum ferritin
29. Correct: C. Hct less than 24% ACD is characterized by a normocytic, normochromic anemia. This is due to a reduced erythropoietic respons in the bone marrow resulting in RBC hypoproliferation However, anemia seldom reaches severe status, with Hc at or above 24% (C). Incorrect: ACD is characterized by a normocytic, normochromic anemia. As this is not an evolving anemia, RDW is within normal limits. Micronutrient deficiency is not an issue in ACD, thus ferritin levels (D) and Hgb produc- tion (MCHC [B]) are within normal levels.
3. Which of the following is most consistent with IDA? A. low MCV, normal MCH B. low MCV, low MCH C. low MCV, elevated MCH D. normal MCV, normal MCH
3. Correct: B. low MCV, low MCH Iron deficiency will inhibit the normal production of Hgb. As 90% of RBCs consist of Hgb ("heme" = iron; "globin" = protein), diminished production of Hgb will result in smaller RBCs (microcytic) with low MCH (B). Incorrect: Wintrobe's classification is used to categorize anemia as microcytic (low MCV), normocytic (MCV within nor- mal limits), or macrocytic (abnormally high MCV). IDA is characterized as a microcytic anemia with low MCH resulting from decreased production of Hgb.
30. When counseling a patient about the neurological alterations often associated with vitamin B12 deficiency, the NP advises that: A. these usually resolve within days with appropriate therapy. B. if present for longer than 6 months, these changes are occasionally permanent. C. the use of parenteral vitamin B12 therapy is needed to ensure symptom resolution. D. cognitive changes associated with vitamin B12 deficiency are seldom reversible even with appropriate therapy.
30.Correct: B. if present for longer than 6 months, these changes are occasionally permanent. Pernicious anemia is treated with oral or parenteral vitamin B12. Improvement in neurological symp- toms can occur quickly with treatment. However, if neurological abnormalities have been present for 6 months or longer, the changes are occasionally permanent even with appropriate vitamin B12 repletion therapy (B). Incorrect: The hematological response to vitamin B12 therapy for pernicious anemia is rapid, with reticulocytosis peaking in 5 to 7 days. Reversal of neurological symptoms occurs more slowly (A), though some improvement is seen quickly. Neurological symptoms, including cognitive changes, are usually reversible if they were present for less than 6 months (D). Vitamin B12 can be administered orally or parenterally (C). However, parenteral therapy is recommended, as the oral form can be absorbed errati- cally and lead to treatment failure.
31. When the cause of a macrocytic anemia is uncertain, the most commonly recommended additional testing includes which of the following? A. haptoglobin and reticulocyte count B. Schilling test and gastric biopsy C. MMA and homocysteine D. transferrin and prealbumin
31. Correct: C. MMA and homocysteine The most common causes of a macrocytic anemia are due to folate-deficiency anemia and pernicious anemia caused by malabsorption of vitamin B12 (a member of the cobala- min family). If the diagnosis of a macrocytic anemia is still uncertain following serum folate and cobalamin testing, additional follow-up tests include serum homocysteine (elevated in folate and vitamin B12 deficiency) and serum MMA (elevated in vitamin B12 deficiency only) (C). Incorrect: Tests for serum MMA and homocysteine can be used to differentiate between folate-deficiency anemia and perni- cious anemia when a macrocytic anemia is encountered. The other tests listed are not specific or particularly useful in trying to diagnose a macrocytic anemia.
32. A 66-year-old man is recently diagnosed with advanced colon cancer. A hemogram reveals the following: Hgb = 9.7 g/dl Hct = 30% RBC = 2.7 million mm3 MCV = 69 fl. MCHC = 27.2 g/dL RDW = 18.4% Next-step testing for this patient should be serum: A. ferritin. B. folate. C. cobalamin. D. homocysteine.
32. Correct: A. ferritin. A patient diagnosed with advanced colon cancer and anemia is most likely experiencing chronic low-volume blood loss from the GI tract. This will likely cause IDA, which is consistent with the hemogram findings of a microcytic anemia and elevated RDW. A serum ferritin test (A) will help to confirm the diagnosis of IDA. Incorrect: Folate-deficiency anemia and pernicious anemia are macrocytic anemias. Initial testing for a macrocytic anemia can include serum folate (B) or cobalamin (C; member of vitamin B, family). If initial testing is incon- clusive, further testing for serum homocysteine (D) and MMA can be used to differentiate between these two types of anemia.
33. A 46-year-old woman complains of a 2-month history of tiredness as well as a progressive worsening of short-term memory and coordination. Her hemogram is as follows: Hgb = 10 g/dL Hct = 30% BC = 3.7 million mm3 MCV = 118 fL MCH = 32 pg RDW = 19.4% Next-step testing for this patient should include: A. cobalamin. B. ferritin. C. thyrotropin (TSH). D. head computed tomography (CT).
33, CorreckA. CoDdl. The most common macrocytic anemias are folate- deficiency anemia and pernicious anemia. The presence of neurological symptoms would suggest a vitamin B12 deficiency. Testing for cobalamin levels (a member of the vitamin B12 family) would be most appropriate (A), though folate, homocysteine, and MMA may also be included to make the differential diagnosis. Incorrect: Serum ferritin (B) would be appropriate in the presence of a microcytic anemia due to iron deficiency. The pres- ence of anemia would also suggest that the symptoms are related to a hematological disorder and not a thyroid disorder requiring TSH testing (C). A head CT scan is not indicated for this patient (D).
34. You see a 36-year-old man with a history of depression. He states that he drinks about a six-pack of beer every night and primarily eats from fast-food restaurants. His diet consists of very little consumption of fruits and vegetables. His hemogram is as follows: Hgb = 10.4 g/dL Hct = 31% RBC = 3.8 million mm' MCV = 116 f MCHC = 33.1 g/dL RDW = 17.6% Next-step testing for this patient should include: A. ferritin. B. folate. C. Hgb electrophoresis. D. No further testing is needed.
34. Correct: B. folate. Excessive alcohol consumption can be associated with mild macrocytosis without anemia. The presence of a macrocytic anemia with elevated RDW suggests an evolving disease process beyond excessive alcohol use. Given his poor diet lacking in fruits and vegetables, he is most likely deficient in folic acid. Testing for serum folate would be most appropriate (B). Additional testing to make the differential diagnosis of a macrocytic ane- mia can include cobalamin, homocysteine, and MMA. Incorrect: Serum ferritin (A) would be used to test for IDA that is characterized as a microcytic anemia. Hgb electro- phoresis (C) would be used to detect for defective Hgb present in the thalassemias. As this anemia cannot be attributed solely to excessive alcohol consumption, additional testing is needed to make the differential diagnosis (D).
35. Prolonged use of PPIs can lead to which micronutrient deficiency that can contribute to anemia? A. vitamin D B. folate C. vitamin B12 D. potassium
35. Correct: C. vitamin B12 Consistent, prolonged use of PPIs, such as omeprazole and lansoprazole, can result in decreased absorption of vitamin Ba (C). PPIs not only block the release of gastric acid but also inhibit the release of intrinsic factor that is required for vitamin B12 absorption. PPI use can also decrease absorption of dietary iron. Incorrect: PPI use has been associated with an increased risk of vitamin and mineral deficiencies, including vitamin By vitamin C, calcium, iron, and magnesium. Though folate deficiency (B) can lead to anemia, absorption of this micronutrient is less likely to be affected by PPI use when compared to vitamin B,: Absorption of potassium (D) and vitamin D (A) is not substantially impacted with PPI use, and deficiencies in these micro- nutrients are not associated with anemia.
36 to 40. Anemia: True or False 36. Anemia in children is potentially associated with poorer school performance. 37. During pregnancy, folic acid requirements increase two- to fourfold. 38. The BC content is approximately 90% Hgb. 39. Approximately 90% of the body's erythropoietin is produced by the kidney. 40. The body's normative response to anemia is reticulocytopenia.
36. Correct: True As the signs of anemia can include fatigue, headache, and poor exercise tolerance, these can negatively impact school performance in children. 37. Correct: True During pregnancy, folic acid is essential in the normal neural tube development by the fetus. Therefore, women planning a pregnancy should take additional amounts of folic acid for 3 months prior to conception, and supple- mentation should continue through lactation. 38. Correct: True Approximately 90% of a RBC is composed of Hgb, and the normal MCHC is 31 to 37 g/dL. An MCHC of less than 31 g/dL will lead to pale (hypochromic) RBCs, often seen in IDA as well as thalassemias. 39. Correct: True The majority of erythropoietin produced in the body is made in the kidneys. During renal impairment (e.g., GFR less than 30 to 40 mL/min), renal erythropoietin production diminishes and can result in a hypoprolifera- tive, normochromic, normocytic anemia.
4. One of the earliest laboratory markers in evolving macrocytic or microcytic anemia is: A. an increase in RDW. B. a reduction in measurable Hgb. C. a low MCH level. D. an increased platelet count.
4. Correct: A. an increase in RDW. RDW reflects the degree of variation in BC size and is often the first abnormal finding in the hemogram of a person with an evolving microcytic or macrocytic anemia. During an evolving anemia, the new cells can be smaller (microcytic anemia) or larger (macrocytic anemia) than older cells, thus elevating the RDW (A). For example, IDA is characterized by microcytosis as new cells are smaller in size due to iron deficiency and reduced Hgb production. Incorrect: An evolving microcytic anemia can be characterized by a reduction in measurable Hgb (B) and/or a low MCH level (C), as is seen in IDA, but this would not be neces- sarily true for an evolving macrocytic anemia (e.g., perni- cious anemia or vitamin B, deficiency anemia). Platelet count (D) is not used as a marker for anemia.
41. Tom is a 19-year-old man who presents with sudden onset of edema of the lips and face and a sensation of "throat tightness and shortness of breath" after a bee sting. Physical examination reveals inspiratory and expiratory wheezing as well as pruritic wheals on his face and arms. Blood pressure is 78/44 mm Hg, heart rate is 102 bpm, and respiratory rate is 24/min. His clinical presentation is most consistent with the diagnosis of: A. vasculitis. B. angioedema. C. anaphylaxis. D. reactive airway disease.
41. Correct: C. anaphylaxis. Though the presentation of anaphylaxis can be highly variable, the most common symptoms include urticaria, angioedema, upper airway angioedema, hypotension, and wheeze that develops over a relatively short period of time. The overall physical findings of this patient are most consistent with anaphylaxis. Incorrect: Vasculitis (A), or inflammation in blood vessels, can develop over a prolonged period of time (days to months) and can include fever, weight loss, head- ache, and fatigue. Though this patient is experiencing angioedema (B), or swelling of the lips and face, this is one sign of a larger disease process the patient is expe- riencing. Though wheezing is a sign of reactive airway disease (D), this diagnosis would not explain the con- stellation of physical findings of this patient, including angioedema and hypotension.
42. Your priority in caring for Tom, the aforementioned patient, is to: A. administer a rapidly acting oral antihistamine. B. administer parenteral epinephrine. C. initiate vasopressor therapy. D. administer a parenteral systemic corticosteroid.
42. Correct: B. administer parenteral epinephrine. When anaphylaxis is suspected, first-line treatment is parenteral epinephrine, preferably given IM in the lateral thigh. There is no contraindication to epinephrine in anaphylaxis, and a failure or delay in administration is associated with greater risk of fatality. Incorrect: Parenteral or oral antihistamine (A) is considered a second-line treatment for anaphylaxis but should not replace epinephrine. Similarly, vasopressors (C) and IV fluid can be used to maintain circulation following epinephrine administration. Systemic corticosteroids (D) have not been shown to improve the course of acute anaphylaxis but may help in preventing recurrent or pro- traced anaphylaxis.
43. Which of the following food-based allergies is likely to be found in adults and childrer A. milk B. egg C. soy D. peanut
43. Correct: D. peanut Food allergies are more common in children than adults, though persistence of some food allergies can extend into adulthood. Of the most common food allergies, peanut (D), tree nut, fish, and shellfish are most likely to persist in adults. Incorrect: Eight foods account for nearly 90% of food allergies and include peanuts, tree nuts, fish, shellfish, eggs, milk, wheat, and soy. Allergies caused by milk (A), egg (B), soy (C), and wheat are more likely to resolve in children.
44. A person with latex allergy also often has a cross-allergy to all of the following except: A. banana. B. avocado. C. kiwi. D. romaine lettuce.
44. Correct: D. romaine lettuce. Individuals with an allergic reaction to natural rubber latex protein can experience cross-reactivity to certain fruit proteins. However, romaine lettuce does not con- tain these proteins for cross-reactivity (D). Incorrect: Fruits that contain proteins that can lead to cross- reactivity with a natural rubber latex allergy include bananas (A), avocado (B), kiwi (C), melons, and chest- nuts. Individuals with a known allergy to natural rubber latex should be educated on avoidance of these foods to prevent severe allergic episodes.
45. The most common clinical manifestation of systemic anaphylaxis typically is: A. dizziness. B. airway obstruction. C. urticaria. D. Gl upset.
45. Correct: C. urticaria. The clinical presentation of anaphylaxis can be unpre- dictable, and an initial mild reaction can rapidly pro- gress to a life-threatening condition. The most common findings in anaphylaxis are urticaria (i.e., hives) and angioedema, found in approximately 85% to 90% of cases. Incorrect: Urticaria and angioedema are the most common findings in anaphylaxis; however, respiratory com- promise and cardiovascular collapse are of greatest concern as they are the most frequent causes of death. Dizziness (A), syncope, and hypotension occur in 30% to 35% of cases, upper airway angioedema (B) occurs in 50% to 60% of cases, and GI upset (D) is experienced by 25% to 30% of those during an anaphylaxis episode.
46. Second-line drug intervention in the presence of anaphylaxis should be: A. oral diphenhydramine. B. nebulized pentamidine. C. nebulized epinephrine. D. oral prednisone.
46. Correct: A. oral diphenhydramine. When anaphylaxis is suspected, first-line treatment is parenteral epinephrine. Parenteral or oral antihista- mine, such as diphenhydramine (A), is considered a second-line treatment for anaphylaxis but should not replace epinephrine. Incorrect: Epinephrine (C) is first-line treatment for anaphylaxis, though this should be administered preferably via IM injection in the lateral thigh. Systemic corticosteroids, such as oral prednisone (D), have not been shown to improve the course of acute anaphylaxis but may help in preventing recurrent or protracted anaphylaxis. Pen- tamidine (B), an antimicrobial, is not recommended for treatment of anaphylaxis.
47. Which of the following is the best answer regarding anaphylaxis? A. Adults usually do not develop new anaphylaxis triggers such as food allergies. B. Peanuts are the only primary food that can cause a severe allergic reaction. C. Future anaphylactic reactions will become increasingly more severe. D. Trace amounts of an allergen in a food can cause a severe anaphylactic reaction.
47. Correct: D. Trace amounts of an allergen in a food can cause a severe anaphylactic reaction. For individuals with food allergies, small amounts of the allergen present in food can elicit a severe IgE-mediated immune reaction that causes anaphylaxis. Following anaphylaxis, individuals should be referred to an aller- gist or immunologist to confirm the cause of the allergic reaction and reduce risk factors for future episodes. Incorrect: Though food allergies are more common in children, adults can have food allergies that reflect either per- sistence of childhood allergies or the origination of an allergy from a new sensitization (A). Peanuts are one of the most common food sources to cause severe and fatal allergic reactions, which also include tree nuts, fish, and shellfish (B). Many food allergies in children resolve over time, particularly allergies caused by milk, egg, wheat, and soy (C).
49. Which of the following plays an essential role in type 1 hypersensitivity? A. immunoglobulin E B. immunoglobulin A C. immunoglobulin G D. immunoglobulin F
49. Correct: A. immunoglobulin E Anaphylaxis is a manifestation of a type I hypersensi- tivity reaction resulting from an IgE-mediated immune reaction. Type I immediate hypersensitivity reactions can involve the rapid release of histamine and other mediators from mast cells and basophils. Incorrect: Immunoglobulin A and immunoglobulin G play an important role in the immune system and are involved in fighting bacteria, viruses, and toxins. However, IgA (B) and IgG (C) are not involved in type I hypersen- sitivity reactions. There is no immunoglobulin F (D).
5. A 48-year-old woman developed IDA after excessive perimenopausal vaginal bleeding, successfully treated by endometrial ablation. Her Hct level is 25%, and she is taking iron therapy. At 5 days into therapy, one possible observed change in laboratory parameters would include: A. a correction of mean cell volume. B. an 8% increase in Hct level. C. reticulocytosis. D. a correction in ferritin level.
5. Correct: C. reticulocytosis. For a patient being treated for IDA with iron therapy, an early sign of recovery is reticulocytosis (C), or the pro- duction of new immature RBCs (reticulocytes). Reticulo- cytosis begins quickly after iron therapy and peaks 7 to 10 days into therapy. Incorrect: Reticulocytosis is the earliest sign of response to iron therapy in IDA. Hgb can increase at a rate of 2 g/dI every 3 weeks in response to iron therapy, which would correlate with an estimated 6% increase of Hct level (B). A normal ferritin level should be achieved after 4 months of therapy (D). Given the 90- to 120-day life span of RBCs, the correction of MCV should be observed after 2 to 4 months of therapy and the elimination of microcytic cells (A).
50. Of the following medications, which is least likely to be implicated as a trigger for anaphylaxis? A. ibuprofen B. amoxicillin C. acetaminophen D. aspirin
50. Correct: C. acetaminophen Certain medications have been associated with IgE-and non-IgE-mediated anaphylaxis. However, acetamino- phen use is not typically associated with anaphylaxis. Incorrect: Medications that have been implicated in anaphylaxis include certain antimicrobials (i.e., members of the penicillin class such as amoxicillin [B]), aspirin (D), and NSAIDs (e.g., ibuprofen [A]).
51. The time to Cmax of epinephrine is shorter when the medication is given: A. IM in the vastus lateralis. B. subcutaneously in the abdominal wall. C. IM in the deltoid. D. IM into the gluteus.
51. Correct: A. IM in the vastus lateralis. Pharmacokinetic studies in healthy volunteers demon- strate that Cmax of epinephrine is achieved in the shortest amount of time when it is administered via IM injection to the vastus lateralis (lateral thigh). Incorrect: Parenteral epinephrine is the initial drug of choice for the management of anaphylaxis, and a delay in admin- istration can increase the risk of death. Epinephrine is typically given subcutaneously or via IM injection in the lateral thigh or deltoid muscle. However, the fastest Cmax is achieved when given IM in the lateral thigh.
52. The use of a systemic corticosteroid in the treatment of anaphylaxis is primarily helpful for: A. treatment of the most acute symptoms. B. minimization of a protracted allergic response. C. prevention of future episodes. D. reducing the risk of fatality associated with the event.
52. Correct: B. minimization of a protracted allergic response. Systemic corticosteroids in anaphylaxis have been shown to prevent recurrent or protracted episodes. Incorrect: Evidence is lacking on the benefits of systemic cortico- steroids in altering the course (A) or preventing death (D) during acute anaphylaxis. These agents will also not prevent future anaphylaxis if the individual is exposed to the allergen (C).
6. A healthy 34-year-old man asks whether he should take an iron supplement. You respond that: A. this is a prudent measure to ensure health. B. IDA is a common problem in men of his age. C. use of an iron supplement in the absence of a documented deficiency can lead to iatrogenic iron overload. D. excess iron is easily excreted.
6. Correct: C. use of an iron supplement in the absence of a documented deficiency can lead to iatrogenic iron overload. For healthy men without documentation of iron defi- ciency, the use of an iron supplement is not recom- mended due to the risk of iatrogenic iron overload (also called secondary hemochromatosis) (C). This results in the extra iron being deposited within the organs of the body that can have toxic effects, including cirrhosis, dia- betes, joint pains, and hypothyroidism. Incorrect: Iron supplementation in healthy men is not recom- mended or needed without documentation of iron deficiency (A). IDA is not a common condition in healthy younger males and so iron supplementation as prophylaxis is not recommended (B). Excess iron can be deposited and stored in the solid organs, rather than be excreted, which can have toxic effects on the body (D).
7. Which of the following is the best advice on taking ferrous sulfate to enhance iron absorption? A. "Take with other medications. B. "Take on a full stomach.? C. "Take on an empty stomach." D. "Do not take with vitamin C."
7. Correct: C. "Take on an empty stomach." A variety of foods and medications can inhibit the absorption of oral iron. Therefore, iron supplements should be taken on an empty stomach to maximize absorption (C). Incorrect: Iron supplements can cause GI upset that can be mini- mized by taking iron with food. However, this can reduce iron absorption by up to two-thirds (B). Milk, calcium, and antacids can also decrease iron absorption and should not be taken with iron supplements. The bioavail- ability of a large number of medications can be impacted when taken at the same time as iron (A), including cer- tain antibiotics, bisphosphonates, and levodopa. Iron sup- plements should be taken at least 2 hours before or after administration of other medications, though concomi- tant use of certain medications should be avoided (e.g., angiotensin-converting enzyme [ACE] inhibitors, fluoro- quinolones). Vitamin C taken with iron supplements can improve absorption (D).
8. A 40-year-old woman with pyelonephritis is taking two medications: ciprofloxacin and ferrous sulfate (for IDA). She asks about taking both medications. You advise that: A. she should take the medications with a large glass of water. B. an inactive drug compound is potentially formed if the two medications are taken together. C. she can take the medications together to enhance adherence to therapy. D. the ferrous sulfate potentially slows GI motility and results in enhanced ciprofloxacin absorption.
8. Correct: B. an inactive drug compound is potentially formed if the two medications are taken together. Iron is a strong chelating agent that binds to a num- ber of other medications, including ciprofloxacin, that reduces bioavailability and effectiveness. Therefore, iron supplements and fluoroquinolones should be taken at least 6 hours apart to minimize any drug-drug interaction. Incorrect: Due to drug-drug interaction potential, the two med- ications should not be taken together (A, C), as this will decrease the bioavailability of ciprofloxacin (D). To improve absorption of iron, it should be taken on an empty stomach, though vitamin C can also improve iron absorption. To minimize drug-drug interactions, iron supplements should be taken at least 2 hours before or after other medications, though some medications may require greater spacing or avoidance.
9. Two months into therapy for pernicious anemia, you wish to check the efficacy of the intervention. The best laboratory test to order at this point is a(n): A. Schilling test. B. Hgb measurement. C. reticulocyte count. D. serum cobalamin.
9. Correct: B. Hgb measurement. Full hematological recovery for pernicious anemia usually takes about 2 months after initiation of therapy with vitamin B12 at the 2-month follow-up, an Hgb measurement would be the most appropriate test to check for efficacy of treatment (B). Incorrect: In pernicious anemia, the hematological response to treatment is generally rapid. Reticulocytosis is brisk and peaks at 5 to 7 days after treatment initiation (C), which would be a more appropriate time to obtain a reticulo- cyte count as a measure of efficacy early in treatment. Similarly, serum cobalamin should return to normal levels early with vitamin B, treatment (D). The Schilling test is used to determine if the body is absorbing vitamin B. 12 properly and should be performed at the time of diagnosis of pernicious anemia (A).
