Hematologic Disorders
Mindy, age 6, was recently discharged from the hospital after a sickle cell crisis. You are teaching her parents to be alert to the manifestations of splenic sequestration and tell them to be alert to: 1.Vomiting and diarrhea. 2.Decreased mental acuity. 3.Abdominal pain, pallor, and tachycardia. 4.Abdominal pain and vomiting.
Abdominal pain, pallor, and tachycardia.
Marsha states that a relative is having a carcinoembryonic antigen (CEA) test done to detect some type of cancer. She wants to know what kind. You tell her a CEA is performed to detect: 1.Adenocarcinoma of the prostate. 2.Medullary cancer of the thyroid. 3.Adenocarcinomas of the colon, lung, breast, ovary, stomach, and pancreas. 4.Multiple myeloma.
Adenocarcinomas of the colon, lung, breast, ovary, stomach, and pancreas.
19. The lab index that has demonstrated reliability as an early marker of microcytic and macrocytic anemias is the: A. MCH. B. MCHC. C. MCV. D. RDW.
Answer/Rationale: 19. D. An increase in RDW beyond the normal range of 15% is seen in early attempts to maintain hematologic homeostasis. Marked reticulocytosis results in transient changes to the RDW because the reticulocytes differ in size from the cells produced under healthy conditions.
38. An 80-year-old Caucasian alcoholic male complains of fatigue, glossitis, and occasional palpitations. He denies neurological complaints. His CBC reveals the following: Hgb 8.0 g/dL, Hct 24%, and MCV 110. Which would be the most likely diagnosis? A. Anemia of chronic disease B. Folic acid deficiency anemia C. Iron deficiency anemia D. Vitamin B12 deficiency anemia
Answer/Rationale: 38. B. A deficiency in folate typically causes macrocytosis without neurological manifestations. The most common causes are inadequate dietary intake, malnutrition, and excessive alcohol intake. Folate food sources include green leafy vegetables, grains, beans, and liver. The classic presentation is an elderly patient and/or alcoholic older male with signs and symptoms of anemia such as weakness, fatigue, difficulty concentrating, irritability, headache, palpitations, or shortness of breath.
43. Following an upper respiratory infection, a 5-year-old boy presents to the clinic with his mother for complaints of unexplained purple discolorations to his upper and lower extremities, frequent nosebleeds, and petechiae. The CBC reveals a decreased platelet count. Which diagnosis is most likely? A. Aplastic anemia B. Idiopathic thrombocytopenia purpura C. Sickle cell disease D. Thrombotic thrombocytopenia purpura
Answer/Rationale: 43. B. Idiopathic thrombocytopenia purpura (ITP) is a syndrome characterized by a decreased number of platelets causing a reduced ability for primary clotting leading to purpura and petechiae. The cause is unknown, but in children, most cases are acute and tend to follow a viral illness. The condition is diagnosed with a CBC and isolated thrombocytopenia is the hallmark finding.
44. Which of the following is a potential complication for a patient diagnosed with heparin-induced thrombocytopenia? A. Bleeding B. Epistaxis C. Pulmonary embolism D. Purpura
Answer/Rationale: 44. C. Heparin-induced thrombocytopenia (HIT) is a complication of heparin therapy and is caused by antibodies that bind to heparin and platelet factor 4 (PF4), causing a prothombotic state. Unlike other forms of thrombocytopenia, HIT presents without bleeding; rather, venous thromboembolism, pulmonary embolism, MI, and CVA are the causes for concern.
45. The nurse practitioner recognizes that the first-line treatment of choice for ITP in children includes which of the following therapies? A. RBC transfusion B. Rituximab C. Single dose of IVIG D. Splenectomy
Answer/Rationale: 45. C. Acute cases of ITP in children generally do not require treatment and resolve spontaneously within 2 months. For children requiring treatment (platelets less than 50,000/μL), a single dose of IVIG dosed at 0.8-1g/kg or a short course of corticosteroids should be used as first-line therapy. Rituximab is used for those with refractory disease.
Which of the following indicate that Jim, a 32-year-old client with AIDS, has oropharyngeal candidiasis? 1.Small vesicles. 2.White, fissured, thickened patches. 3.Removable white plaques. 4.Flat-topped papules with thin, bluish-white spiderweb lines.
Removable white plaques.
Your client Mrs. Young, age 64, is here to see you because she has pain in her left breast. She reports no pain in her right breast and no noted lesions or masses on breast self-exam, which she performs monthly. You know that: 1.At her age, you do not need to worry about breast cancer. 2.Initial presentation of breast pain is usually not suspicious for malignancy. 3.She must be sent for a mammogram as soon as possible. 4.She has no personal or family history of breast cancer; therefore, you are not concerned.
She must be sent for a mammogram as soon as possible.
Shelley has esophageal cancer and asks you if cigarettes and alcohol played a part in its development. How do you respond? 1."Your cancer was caused by your cigarette smoking, nothing else." 2."Alcohol is also a carcinogen." 3."Alcohol directly alters DNA and causes mutations." 4."Alcohol modifies the metabolism of carcinogens in the esophagus and increases their effectiveness."
"Alcohol modifies the metabolism of carcinogens in the esophagus and increases their effectiveness."
16. What is the most likely diagnosis for a patient with the following CBC findings? WBC: 7.1 C 103/μl RBC: 3.32 × 103/μl Hgb: 11.3 g/dL Hct: 34.4% MCV: 91 fL MCHC: 32 g/dL Plt: 364 × 103/μl RDW: 13.4% Reticulocytes: 0.9% A. Anemia of chronic disease B. Folate deficiency anemia C. Iron deficiency anemia D. Vitamin B12 deficiency anemia
Answer/Rationale: 16. A. The MCV of this patient with anemia reveals a normocytic anemia. Iron deficiency anemia is a microcytic anemia, while folic acid and vitamin B12 deficiencies result in the production of RBCs that are larger in size than normal cells, macrocytic anemia.
17. What is the most likely diagnosis for a patient with the following CBC findings? WBC: 8.8 × 103/μl RBC: 3.01 × 103/μl Hgb: 10.3 g/dL Hct: 32.2% MCV: 74 fL MCHC: 28.3 g/dL Plt: 400 × 103/μl RDW: 18.4% Reticulocytes: 2.1% A. Anemia of chronic disease B. Folate deficiency anemia C. Iron deficiency anemia D. Vitamin B12 deficiency anemia
Answer/Rationale: 17. C. The MCV of this patient with anemia reveals a microcytic anemia. Anemia of chronic disease is most commonly a normocytic anemia, while folic acid and vitamin B12 deficiencies result in the production of RBCs that are larger in size than normal cells, which is called macrocytic anemia.
18. Which diagnostic test could help identify whether the cause of anemia is hemolytic in nature? A. Bone marrow aspiration B. Direct antiglobulin test C. Hemoglobin electrophoresis D. Serum haptoglobin
Answer/Rationale: 18. D. Standard blood tests for the workup of suspected hemolytic anemia include a CBC with peripheral smear, serum LDH, serum haptoglobin, and indirect bilirubin. Changes in the LDH and serum haptoglobin are the most sensitive of these tests. Within intravascular hemolysis, free hemoglobin is released into the circulation and quickly bound by haptoglobin; thus, circulating haptoglobin levels decline.
20. The FNP is seeing a patient who has been taking ferrous sulfate. Which statement by the patient demonstrates a need for additional education? A. "I should take my medication with orange juice to increase absorption." B. "I should take one tablet twice a day." C. "It is best to take the iron on an empty stomach." D. "It is recommended that I take enteric coated iron with meals."
Answer/Rationale: 20. D. Iron is best absorbed when taken on an empty stomach, but does have GI effects that limit tolerability (i.e., nausea and epigastric discomfort); taking iron supplementation with food can decreased absorption by two-thirds and the use of enteric-coated preparations limits the absorption in the duodenum. Ascorbic acid does enhance iron absorption in the GI tract.
37. A 60-year-old female is following up with the nurse practitioner for a recent diagnosis of pernicious anemia, and she would like to know how long she will need to continue treatment with Vitamin B12. The most appropriate response by the nurse practitioner is: A. 1-3 months. B. 3-6 months. C. 6-12 months. D. Lifelong.
Answer/Rationale: 37. D. Pernicious anemia is an autoimmune disorder caused by the destruction of parietal cells in the gastric fundus, resulting in the cessation of intrinsic factor production. The intrinsic factor is important for the absorption of vitamin B12 from the small intestine. Since pernicious anemia is irreversible, lifetime supplementation of B12 (injections, nasal, or high-dose oral route) is necessary.
39. The nurse practitioner is following up with a patient who was recently diagnosed with vitamin B12 deficiency. To assess the effectiveness of dietary education, the FNP should focus on the patient's intake of which food source? A. Broccoli B. Chicken C. Legumes D. Lettuce
Answer/Rationale: 39. B. Vitamin B12 is naturally found in animal products, including fish, meat, poultry, eggs, milk, and milk products. Vitamin B12 is generally not present in plant-based foods, but fortified breakfast cereals are an option for strict vegetarians.
4. The FNP is evaluating a CBC that reveals an abnormally low Hgb, Hct, and RBC count. Which of the following lab values would assist the FNP in determining if the anemia was microcytic or macrocytic? A. Ferritin level B. MCV C. MCHC D. TIBC
Answer/Rationale: 4. B. The mean cell volume is the lab value that reflects RBC size or average volume. Based on MCV, cells are classified as normocytic (80-100 femtoliters [fL]), microcytic (< 80 fL), or macrocytic (> 100 fL).
40. A monocyte count comprising 20% of leukocytes within the CBC is likely a result of which of the following? A. An allergic response B. An autoimmune disorder C. An acute bacterial infection D. A parasitic disease
Answer/Rationale: 40. B. Monocytes are the largest of the WBCs and comprise 2-8% of the leukocyte count. Monocytes are produced in the bone marrow and migrate from blood to tissue within a few hours, where they develop into macrophages and dendritic cells. Monocytes assist other leukocytes to remove dead or damaged tissues, destroy cancer cells, and regulate immunity against foreign substances. Monocytosis may occur in response to chronic infections, autoimmune disorders, blood disorders, or cancers.
41. Microangiopathic hemolytic anemia, thrombocytopenic purpura, neurologic abnormalities, fever, and renal disease are associated with which hematologic syndrome? A. Idiopathic thrombocytopenic purpura B. Immune heparin induced thrombocytopenic purpura C. Nonimmune heparin induced thrombocytopenic purpura D. Thrombotic thrombocytopenic purpura
Answer/Rationale: 41. D. Thrombotic thrombocytopenic purpura is a syndrome of decreased platelets causing microangiopathic hemolytic anemia, thrombocytopenic purpura, neurologic abnormalities, fever, and renal disease. Although not all patients present with the classic pentad of symptoms, the presence of microangiopathic hemolytic anemia and thrombocytopenia alone should prompt suspicion of TTP.
42. The nurse practitioner is following up with a patient who was recently diagnosed with beta thalassemia major. The nurse practitioner recognizes that the life expectancy of someone with this disorder is: A. 15 years. B. 30 years. C. 45 years. D. 60 years.
Answer/Rationale: 42. B. Although persons with thalassemia trait have a normal life expectancy, patients with beta thalassemia major often die from cardiac complications from iron overload related to regular blood transfusions by 30 years of age.
46. A 12-year-old boy with fatigue, dyspnea, pallor, and easy bruising presents for evaluation by the nurse practitioner. Hemogram evaluation reveals pancytopenia. Which test should be utilized to confirm the suspected diagnosis? A. ANA screen B. Bone marrow biopsy C. Folate level D. Hgb electrophoresis
Answer/Rationale: 46. B. Aplastic anemia is a serious blood disorder caused by bone marrow failure characterized by pancytopenia and marrow hypoplasia. Therefore, the first tests to order when evaluating a patient for suspected aplastic anemia include a CBC with differential reticulocyte count, peripheral blood smear, and a bone marrow biopsy with cytogenic evaluation. A bone marrow biopsy typically demonstrates hypocellular marrow without abnormal cells.
47. Bleeding and bruising are most likely to occur as a result of which condition? A. Leukopenia B. Lymphocytopenia C. Thrombocytopenia D. Thrombocytosis
Answer/Rationale: 47. C. Thrombocytopenia is defined as a platelet count of less than 150,000/μL and is often found incidentally when obtaining a CBC. Most patients with thrombocytopenia are asymptomatic. However, when platelet counts decrease to less than 50,000/μL, symptoms may include easy bruising (ecchymosis, petechiae), bleeding from mucous membranes, spontaneous epistaxis, excessive bleeding from wounds, and hematuria.
48. Within which timeframe should the nurse practitioner reevaluate the hemogram of an anemic patient who has started folic acid supplementation? A. 2 weeks B. 4 weeks C. 6 weeks D. 8 weeks
Answer/Rationale: 48. B. The most common recommended dose of folic acid replacement for adults with folic acid deficiency is 1 mg/day. In response to supplementation, reticulocytosis occurs rapidly and peaks within 7 to 10 days. Hematocrit levels usually return to normal within one month and evaluating the hemogram within this timeframe is considered standard. If levels are not rising as expected, and coexisting B12 anemia has been ruled out, the practitioner should keep in mind that iron deficiency anemia coexists in 1/3 of patients with B12 or folate deficiency.
49. A 40-year-old female with iron deficiency anemia returns to the clinic for an early morning appointment after 3 months of iron supplementation to have her CBC and serum iron level drawn. Which statement by the patient may cause the nurse practitioner to reschedule the lab draw? A. "I had a large cup of coffee this morning with breakfast." B. "I have been exercising for 45 minutes every evening." C. "I think the iron pills are causing my stomach to be upset." D. "I took my iron pill while I was in the waiting room."
Answer/Rationale: 49. D. Serum iron levels are highest in the morning and this is an ideal time to evaluate these lab values; however, for the most accurate results, patients should be advised to fast for 8-12 hours prior to the blood draw. Serum iron levels rise earlier in the treatment process and reflect recent intake. Therefore, iron levels are impacted if the patient ingests oral iron supplements within 24-48 hours of a lab evaluation.
5. Which of the following conditions is associated with normocytic anemia? A. A deficiency in vitamin B12 intake or absorption B. Chronic blood loss C. Concurrent chronic illness (i.e., chronic kidney disease) D. Inadequate globin synthesis
Answer/Rationale: 5. C. Normocytic anemia, with an MCV of 80-100fL, correlates with anemia of chronic disease. Chronic blood loss is associated with iron deficiency anemia, a microcytic anemia. Deficiency in vitamin B12 results in the development of macrocytic anemia. Inadequate globin synthesis occurs in beta thalassemia, a microcytic anemia.
8. What laboratory finding on the white blood cell count would lead the nurse practitioner to suspect acute appendicitis as the cause of a client's right lower quadrant abdominal pain? A. Increased lymphocytes with more than 10% atypical lymphs B. Increased neutrophils with more than 10% bands C. Increased total leukocytes, with an increased proportion of basophils D. Increased total leukocytes, with an increased proportion of eosinophils
Answer/Rationale: 8. B. Acute infectious processes stimulate an increase in the production and release of mature neutrophils and mobilization of less mature neutrophils or bands. Normally, the vast majority of neutrophils circulating in the bloodstream are in the mature form, but with acute infectious processes, mobilization of bands can increase the proportion of immature neutrophils to greater than 10%.
9. When interpreting findings in an individual with leukocytosis, the FNP recognizes that a "left shift" is represented by an increase in the proportion of: A. Eosoniphils. B. Lymphocytes. C. Monocytes. D. Neutrophils.
Answer/Rationale: 9. D. The term "left shift" is almost always associated with neutrophils. The left shift means that the population of cells is shifted toward most immature cells, with an increased percentage of immature neutrophils (i.e., bands, metamyeloctyes, and myelocytes) being present to fight infection.
Your client Mr. Jones has Sjögren syndrome. Which treatment do you suggest? 1.Artificial tears and chewing sugarless gum. 2.Frequent rinsing of the mouth with mouthwash. 3.Drinking at least 1 glass of milk per day. 4.Removing wax from the ears at regular intervals.
Artificial tears and chewing sugarless gum.
Sara comes today with numerous petechiae on her arms. You know she is not taking warfarin (Coumadin). What other drugs do you ask her about? 1.Aspirin or aspirin compounds. 2.Antihypertensive agents. 3.Oral contraceptives. 4.Anticonvulsants.
Aspirin or aspirin compounds.
50. A 20-year-old Asian man presents to your clinic for follow-up. He has a history of aplastic anemia and has recently received a hematopoietic cell transplantation. Upon his examination, a generalized maculopapular pruritic rash, with sparing of the scalp, is noted. Which of the following is most imperative for the nurse practitioner to rule out? A. An allergic reaction to a newly initiated medication B. Graft versus host disease C. Recent exposure to school-age children D. Worsening symptomatology of aplastic anemia
Answer/Rationale: 50. B. Patients who undergo hematopoietic cell transplantation have a risk for developing graft versus host disease (GVHD), and possibly graft failure, and should therefore be monitored frequently. The clinical manifestations of acute GVHD occur in the skin, GI tract, and liver, with the skin the most commonly affected organ. The characteristic rash of GVHD is pruritic, maculopapular, and scalp-sparing.
6. The FNP is following up with a patient previously diagnosed with anemia who complains of a sore tongue and numbness and tingling of the hands and feet. The FNP recognizes that she needs to address that you need to address the patient's response to: A. Administration of erythropoietin. B. Ferrous sulfate supplementation. C. Folic acid supplementation. D. Vitamin B12 supplementation.
Answer/Rationale: 6. D. The case presentation is that of vitamin B12 deficiency. Although glossitis may occur with folic acid deficiency, parasthesias of the hands and feet in a stocking/glove distribution are characteristic of pernicious anemia; thus, it is important to evaluate the patient's response to vitamin B12 supplementation.
7. The FNP is following up with a young adult woman previously diagnosed with microcytic, hypochromic anemia. The FNP recognizes that it is important to rule out: A. Abnormal uterine bleeding. B. Gastrointestinal bleeding. C. Inadequate intake of folic acid. D. Low carbohydrate diet fads.
Answer/Rationale: 7. A. In young adult women, abnormal uterine bleeding is a common cause of iron deficiency anemia, a microcytic, hypochromic anemia. Bleeding from the GI tract is a more common cause of IDA in older adults. Inadequate intake of folic acid would result in macrocytic anemia. Low carbohydrate diets still allow for adequate intake of iron from meats and green leafy vegetables.
Which of the following cancers is associated with Epstein-Barr virus? 1.Burkitt lymphoma. 2.Kaposi sarcoma. 3.Lymphoma. 4.Adult T-cell leukemia.
Burkitt lymphoma.
Julia asks how smoking increases the risk of folic acid deficiency. You respond that smoking: 1.Causes small vessel disease and constricts all vessels that transport essential nutrients. 2.Decreases vitamin C absorption. 3.Affects the liver's ability to store folic acid. 4.Causes nausea, thereby inhibiting the appetite and ingestion of foods rich in folic acid.
Decreases vitamin C absorption.
You have a new client, Robert, age 67, who presents with generalized lymphadenopathy. You know that this is indicative of: 1.Disseminated malignancy, particularly of the hematologic system. 2.Cancer of the liver. 3.Sjögren syndrome. 4.Pancreatic cancer.
Disseminated malignancy, particularly of the hematologic system.
Sam is being worked up for pancreatic cancer. He states the doctor wants to put a "scope" in and inject dye into his ducts. He wants to know more about this. What procedure is he referring to? 1.Percutaneous transhepatic cholangiography (PTC). 2.Endoscopic retrograde cholangiopancreatography (ERCP). 3.Angiography. 4.Upper gastrointestinal (GI) series.
Endoscopic retrograde cholangiopancreatography (ERCP).
Which of the following white blood cell types are elevated in parasitic infections, hypersensitivity reactions, and autoimmune disorders? 1.Neutrophils. 2.Eosinophils. 3.Basophils. 4.Monocytes.
Eosinophils.
Which is the best serum test for spotting an iron deficiency early, before it progresses to full-blown anemia? 1.Hemoglobin. 2.Hematocrit. 3.Ferritin. 4.Reticulocytes.
Ferritin.
Which of the following conditions is an X-linked recessive disorder commonly seen in African American males? 1.Sickle cell anemia. 2.Glucose-6-phosphate dehydrogenase deficiency. 3.Pyruvate kinase deficiency. 4.Bernard-Soulier syndrome.
Glucose-6-phosphate dehydrogenase deficiency.
Jimmy, age 6 months, is newly diagnosed with sickle cell disease. His mother brings him to the clinic for a well-baby visit. Which of the following should you do on this visit? 1.Tell his mother that Jimmy will not be immunized because of his diagnosis. 2.Tell his mother that Jimmy should not go to day care. 3.Immunize Jimmy with the diphtheria, tetanus, and pertussis (DTaP); Haemophilus influenzae type b (Hib); hepatitis B virus (HBV); and poliomyelitis vaccines. 4.Immunize Jimmy with the measles, mumps, and rubella; Haemophilus influenzae type b (Hib); and hepatitis B virus (HBV) vaccines only.
Immunize Jimmy with the diphtheria, tetanus, and pertussis (DTaP); Haemophilus influenzae type b (Hib); hepatitis B virus (HBV); and poliomyelitis vaccines.
Your client Jackson has decreased lymphocytes. You suspect: 1.Bacterial infection. 2.Viral infection. 3.Immunodeficiency. 4.Parasitic infection.
Immunodeficiency.
Jan is having biological therapy for her pancreatic cancer. What kind of treatment is this? 1.Surgery. 2.Radiation therapy. 3.Immunotherapy. 4.Chemotherapy.
Immunotherapy.
Jill has just been given a diagnosis of human immunodeficiency virus (HIV) and has a normal initial Pap smear. When do the Centers for Disease Control and Prevention (CDC) guidelines state she should have a repeat Pap test? 1.In 3 months. 2.In 6 months. 3.In 1 year. 4.She should have a colposcopy every year instead of a Pap test.
In 6 months.
A 28-year-old female presents to your primary care office for an annual physical. She denies any complaints other than heavy menstrual bleeding, which is something she has experienced her whole life. On routine complete blood count (CBC) evaluation, her hemoglobin is 11.0. Other pertinent values include a decreased serum ferritin and elevated total iron-binding capacity (TIBC). Her mean corpuscular volume (MCV) is 75. Which of the following is the likely cause of her anemia? 1.Iron deficiency anemia. 2.Thalassemia. 3.Sideroblastic anemia. 4.Anemia of chronic disease (ACD).
Iron deficiency anemia.
Lorie, age 29, appears with the following signs: pale conjunctivae and nail beds, tachycardia, heart murmur, cheilosis, stomatitis, splenomegaly, koilonychia, and glossitis. What do you suspect? 1.Vitamin B12 deficiency. 2.Folate deficiency. 3.Iron deficiency anemia. 4.Chronic fatigue syndrome.
Iron deficiency anemia.
Sherri's blood work returns with a decreased mean corpuscular volume (MCV) and a decreased mean corpuscular hemoglobin concentration (MCHC). What should you do next? 1.Order a serum iron level and a total iron-binding capacity (TIBC) level. 2.Order a serum ferritin level. 3.Order a serum folate level. 4.Order a serum iron level, a total iron-binding capacity (TIBC) level, and a serum ferritin level.
Order a serum iron level, a total iron-binding capacity (TIBC) level, and a serum ferritin level.
Stu, age 49, has slightly reduced hemoglobin and hematocrit readings. What is your next action after you ask him about his diet? 1.Repeat the laboratory tests. 2.Perform a fecal occult blood test. 3.Start him on an iron preparation. 4.Start him on folic acid.
Perform a fecal occult blood test.
Sally has human immunodeficiency virus (HIV) and asks which method of birth control, other than abstinence, would be best for her. You suggest: 1.Latex condoms. 2.The spermicide nonoxynol-9. 3.An intrauterine device (IUD). 4.An oral contraceptive.
Latex condoms.
Samuel, age 5, is receiving radiation therapy for his acute lymphoblastic leukemia. This treatment puts him at increased risk of developing which type of cancer as a secondary malignancy when he becomes an adult? 1.Chronic lymphocytic leukemia. 2.Brain tumor. 3.Liver cancer. 4.Esophageal cancer.
Brain tumor.
Allie, age 5, is being treated with radiation for cancer. Her mother asks about the effect radiation will have on Allie's future growth. Although she knows that a specialist will be handling Allie's care, her mother asks for your opinion. How do you respond? 1."Let's worry about the cancer first and then see how her growth is affected." 2."Chemotherapy may affect her future growth, but radiation will not." 3."She will probably have growth hormone problems, in which case she can then begin growth hormone therapy." 4."That's the least of your worries now; everything will turn out okay."
"She will probably have growth hormone problems, in which case she can then begin growth hormone therapy."
Mandy's 16-year-old daughter has hepatitis A. Which of the following statements made by Mandy indicates she understands the teaching you've just completed? 1."I guess she needs to be hospitalized until she's recovered." 2."We'll keep her at home with strict isolation precautions." 3."We'll stop at the store and buy plastic eating utensils." 4."We'll stop at the drugstore and pick up prescription medications immediately."
"We'll stop at the store and buy plastic eating utensils."
Maria, age 35, asks if being obese predisposes her to cancer. How do you respond? 1."No, you have the same risk as a normal-weight individual." 2."You have less risk of cancer than normal-weight individuals because you have protein stores to combat mutant cells." 3."Yes, you have an increased risk of hormone-dependent cancers because of your obesity." 4."Yes, you have an increased risk because you have many more cells in all the organs of your body."
"Yes, you have an increased risk of hormone-dependent cancers because of your obesity."
Nancy recently had a mastectomy and refuses to look at the site. Her husband does all the dressing changes. When she comes in to the office for a postoperative checkup, what would you say to her? 1."You'll look at it when you're ready." 2."You must look at it today." 3."Everything's going to be okay. It looks fine." 4."You have to accept this eventually; just glance at it today."
"You have to accept this eventually; just glance at it today."
Barbara, age 27, had her spleen removed after an automobile accident. You are seeing her in the office for the first time since her discharge from the hospital. She asks you how her surgery will affect her in the future. How do you respond? 1."Your red blood cell production will be slowed." 2."Your lymphatic system may have difficulty transporting lymph fluid to the blood vessels." 3."You'll have difficulty storing the nutritional agents needed to make red blood cells." 4."You may have difficulty salvaging iron from old red blood cells for reuse."
"You may have difficulty salvaging iron from old red blood cells for reuse."
Joan had a modified radical mastectomy with radiation therapy 10 years ago. She asks when she can have her blood pressure and needle sticks performed in the affected arm. How do you respond? 1."If it's been 10 years and you've had no problems, you can discontinue these precautions." 2."Because you didn't have a radical mastectomy, you can do those things now." 3."You must observe these precautions forever." 4."As long as you do limb exercises and have established collateral drainage, you can discontinue these precautions."
"You must observe these precautions forever."
2. A 20-year-old college student presents with complaints of excessive fatigue, fever, and exudative pharyngitis, which is accompanied by anterior and posterior cervical lymphadenopathy. What WBC findings would support the suspected diagnosis? A. Increased neutrophils with more than 10% bands B. Increased lymphocytes with more than 10% atypical lymphocytes C. Increased total leukocytes, with an increased proportion of basophils D. Increased total leukocytes, with an increased proportion of eosinophils
2. B. The case scenario is consistent with the classic triad seen with infectious mononucleosis: fever, exudative pharyngitis, and adenopathy. Within mono, the characteristic CBC findings include absolute lymphocytosis in which more than 10% of the cells are atypical.
Skip, age 4, is brought to the office by his mother. His symptoms are pallor, fatigue, bleeding, fever, bone pain, adenopathy, arthralgias, and hepatosplenomegaly. You refer him to a specialist. Which of the following tests do you expect the specialist to perform to confirm a diagnosis? 1.An enzyme-linked immunosorbent assay. 2.A monospot test. 3.A prothrombin time, partial thromboplastin time, bleeding time, complete blood count, and peripheral smear. 4.A bone marrow smear.
A bone marrow smear.
12. Women of childbearing age should have an adequate intake of what micronutrient to decrease the risk of fetal neural tube defects? A. Folic acid B. Iron C. Vitamin B6 D. Vitamin B12
Answer/Rationale: 12. A. Folic acid deficiency in early pregnancy has been linked to the teratogenic effect of neural tube defects.
Macrocytic normochromic anemias are caused by: 1.Acute blood loss. 2.An infection or tumor. 3.A nutritional deficiency of iron. 4.A deficiency of folic acid.
A deficiency of folic acid.
13. The most appropriate additional diagnostic test for the patient with decreased WBCs, RBCs, and platelets is a: A. Bone marrow biopsy. B. Direct Coombs' test. C. Hemoglobin electrophoresis. D. Serum haptoglobin.
Answer/Rationale: 13. A. Pancytopenia (a deficiency in all three cellular components of the blood) is indicative of aplastic anemia. A bone marrow aspiration biopsy is needed to rule out myelodysplastic syndrome and metastatic tumor deposits. The hypoplastic bone marrow of aplastic anemia will have fatty replacement which is often accompanied by a relative increase in nonhematopoietic elements (i.e., mast cells).
14. The presence of schistocytes on the peripheral smear of a patient with decreased platelets should raise the suspicion of: A. Autoimmune hemolytic anemia. B. Erythroblastisfetalis. C. Thalassemia major. D. Thrombotic thrombocytopenic purpura.
Answer/Rationale: 14. D. Thrombotic thrombocytopenic purpua is a microangiopathic hemolytic anemia that is accompanied by systemic microvascular thrombosis that can impact any organ(s) within the body. Within this potentially fatal condition, RBCs within the circulation become severed as they come in contact with thrombi within the vessels. The remaining fragmented cell is known as schistocyte. An initial schistocyte count of greater than 1% strongly suggests a diagnosis of TTP in the absence of other known causes of thrombotic microangiopathy.
In which of the following circumstances is the reticulocyte count elevated? 1.Aplastic anemia. 2.Iron deficiency anemia. 3.Poisoning. 4.Acute blood loss
Acute blood loss.
15. The FNP is educating an anemic patient about the procedure(s) for a Schilling test. The practitioner recognizes that a Schilling test involves: A. An early morning, fasting lab draw. B. Collecting urine for 24 hours. C. Endoscopic sampling of the gastric mucosa. D. Serial collections of serum vitamin B12 levels.
Answer/Rationale: 15. B. The Schilling test is used to determine whether the body absorbs vitamin B12 normally. Patients undergoing testing receive two doses of vitamin B12: The first is an oral radioactive form; an intramuscular injection of non-radioactive vitamin B12 is administered one hour later. The patient then collects urine over the next 24 hours, and the specimen is evaluated to determine how much vitamin B12 is excreted in the urine.
1. Iron deficiency typically manifests as: A. Macrocytic, normochromic anemia. B. Microcytic, hypochromic anemia. C. Microcytic, normochromic anemia. D. Normochromic, normocytic anemia.
Answer/Rationale: 1. B. Iron deficiency results in the development of cells that are smaller in size (microcytic) and more pale in color (hypochromic) due to the lack of Hgb during cell synthesis. In the early phases of iron deficiency, cells may actually remain normocytic and normochromic because the bone marrow draws upon stored iron reserves during erythropoiesis. Once the stores have been depleted, the production the erythrocytes formed become microcytic and hypochromic.
10. What organ system is responsible for the majority of the body's production of erythropoietin? A. Bone Marrow B. Kidneys C. Liver D. Spleen
Answer/Rationale: 10. B. 90% of the body's erythropoietin is produced by the kidneys; only about 10% is produced in the liver.
11. An elevated red cell distribution width (RDW) correlates with which of the following findings on the peripheral smear? A. Anisocytosis B. Microcytosis C. Poikilocytosis D. Reticulocytosis
Answer/Rationale: 11. A. Anisocytosis describes variance in RBC sizes that is common in anemia as new cells formed are larger (macrocytic) or smaller (microcytic) than the healthy cells which were formed prior to the underlying processes that resulted in anemia. This variance in sizes of circulating red blood sizes correlates with an increased RDW.
21. An older adult with ESRD who is undergoing hemodialysis is in the office for follow-up. The patient is on erythropoietin therapy, but has not been able to attain a hemoglobin level greater than 9.2 g/dL despite negative assessment for blood loss and other common etiologies known to contribute to hyporesponsiveness to erythropoietin. The patient's haptoglobin and LDH are elevated. Which of the following causes of hemolysis is most likely contributing to the patient's anemia? A. Autoimmune B. Drug-induced C. Hereditary D. Mechanical
Answer/Rationale: 21. D. Patients undergoing hemodialysis are at risk for physical damage to the RBC membranes because it causes them to break down faster than normal. Autoimmune hemolytic anemia is linked to specific diseases (lupus, hepatitis, leukemia, and lymphoma) and infections (EBV, CMV, and HIV). Drug-induced hemolytic anemia is linked to chemotherapy, quinine and antimalarial medications, levodopa, and antiinflammatories, among others). Hereditary or inherited hemolytic anemias (including sickle cell anemia, thalassemia, G6PD deficiency, and hereditary spherocytosis and elliptocytosis) most commonly have manifestations that begin earlier in the lifespan.
22. Which of the following is the leading cause of death in individuals with sickle cell anemia? A. Bacterial infection B. Heart failure C. Kidney failure D. Stroke
Answer/Rationale: 22. A. Although the risk of bacterial infections does decrease in the individual with sickle cell anemia after the age of three years, bacterial infections are still the most common cause of death at any age.
23. When evaluating the patient with megaloblastic anemia who does not have neurological symptoms, the FNP recognizes that the most likely diagnosis is: A. An underlying hemolytic process. B. Folic acid deficiency. C. Iron deficiency. D. Suppression of the bone marrow.
Answer/Rationale: 23. B. Megaloblastic anemia correlates with macrocytic anemia. Of the macrocytic anemias, vitamin B12 commonly produces a variety of neurological symptoms because of its relationship with methylmalonic acid and methionine, while folic acid deficiency does not manifest with neurological symptoms.
24. An older adult who has been hospitalized with macrocytic anemia with an Hgb of 8 g/dl is being seen for follow-up. Because of the degree of anemia, daily vitamin B12 injections for one week have been ordered. What additional labs will be drawn during this follow-up visit? A. Calcium level B. Creatinine and BUN C. Fasting glucose D. Potassium level
Answer/Rationale: 24. D. Vitamin B12 replacement is accompanied by a shift of potassium from the serum to within the cells during reticulocytosis; the risk for hypokalemia is more common in the individual with severe anemia and can be compounded by coexisting conditions or medications that place the individual at risk for hypokalemia or the negative consequences associated with this electrolyte imbalance (e.g., those on diuretics or digoxin).
25. The gold standard for diagnosing sickle cell disease is a(n): A. Bone marrow aspiration. B. Direct antiglobin test. C. Hemoglobin electrophoresis. D. Indirect Coombs' test.
Answer/Rationale: 25. C. Hemoglobin electrophoresis identifies variant and abnormal hemoglobins, including hemoglobin S (HbS) or sickle hemoglobin. It can be used to differentiate those who have sickle cell disease (in which at least one of the two abnormal inherited genes will result in the production of hemoglobin S) and sickle cell anemia (in which the individual has inherited two hemoglobin S genes, hemoglobin SS [HbSS], the most common and severe type of the disease).
26. What therapy is commonly used to prevent acute pain syndrome in children and adults with SCD? A. Hydroxyurea B. Ibuprofen C. Intravenous iron infusions D. Monthly blood transfusions
Answer/Rationale: 26. A. Several studies in children and adults have revealed that hydroxyurea reduces the number of episodes of vaso-occlusive or pain crises and hospitalizations. Therapy with hydroxyurea has also been shown to decrease the need for transfusions. Experts recommend that children and adults with hemoglobin SS who have frequent, painful episodes, recurrent chest crises, or severe anemia requiring transfusions take hydroxyurea daily. Some experts initiate this therapy to all hemoglobin SS children over the age of 9 months to prevent or reduce the chance of complications; safety and effectiveness in children under the age of 9 months has not been established. Ibuprofen is helpful when mild pain crises occur.
27. A seven-year-old boy, recently diagnosed with acute lymphocytic leukemia (ALL), has been receiving induction chemotherapy treatments. Current lab values indicate a WBC count of 4,300/mm3, neutrophils 50%, lymphocytes 15%, monocytes 2%, eosinophils 3%, and basophils 1%. What is his absolute neutrophil count (ANC)? A. 86/mm3 B. 645/mm3 C. 2,150/mm3 D. 3,440/mm3
Answer/Rationale: 27. C. The absolute neutrophil count (ANC) refers to the number of neutrophil granulocytes in the blood and is utilized as a measure of risk for infection in patients undergoing chemotherapy. The ANC is calculated by multiplying the WBC count by the percent of neutrophils (segs and bands) present in the blood. The ANC can be interpreted as follows: • ANC greater than 1500/mm3: No increased risk of infection • ANC 1000-1500/mm3: Slight increase in risk of infection • ANC 500-1000/mm3: Moderate increase in risk of infection • ANC 100-500/mm3: High risk of infection • ANC less than 100/mm3: Extremely high risk of infection
28. A 19-year-old male has beta thalassemia major, which was detected during infancy. He receives frequent RBC transfusions for severe anemia. Which of the following supplements should the patient avoid? A. Folic acid B. Multi-vitamins with iron C. Vitamin B12 D. Vitamin C
Answer/Rationale: 28. B. Iron overload is a major concern for transfusion-dependent patients with thalassemia major, contributing to morbidity and mortality. Each unit of transfused blood has approximately 250 mg of iron, which accumulates in the tissues, especially the liver and heart. Thalassemia major patients commonly undergo iron chelation therapy to minimize their risk of transfusion-induced iron overload complications. Supplementation with iron should be avoided unless there is substantial evidence of an iron deficiency.
36. A 30-year-old female recently began treatment with ferrous sulfate 325 mg PO TID between meals. She presents to the nurse practitioner for a repeat CBC after one month of iron therapy. Lab values are as follows: Hgb 12.0 g/dL, Hct 36%, MCV 82, and MCHC 32 g/dL. What is the most appropriate follow-up course of action by the nurse practitioner? A. Continue current treatment regimen. B. Decrease oral iron supplementation. C. Increase oral iron supplementation. D. Switch to IV iron therapy.
Answer/Rationale: 36. A. An increase in hemoglobin by 1g/dL within one month of iron supplementation demonstrates an adequate response to treatment and confirms the diagnosis of IDA. In adults, therapy should be continued for 3 months after hemoglobin is corrected to restore ferritin stores.
29. A mother of an exclusively breast fed 4-month-old infant presents to the nurse practitioner for a well-child examination. Which of the following recommendations is appropriate at this time to reduce the risk for iron deficiency anemia in the infant? A. Begin supplementation with an iron-rich formula. B. Have the mother take an iron supplement. C. Initiate an oral multivitamin with iron for the baby. D. Introduce iron-rich foods for the baby.
Answer/Rationale: 29. C. The American Academy of Pediatrics (2010) identifies that iron deficiency anemia is a common yet undetected problem among children. Current recommendations include universal iron supplementation for all children, with dosing dependent on the child's age and the anticipated amount of iron consumed. Term, healthy infants have sufficient iron for the first 4 months of life. Human breast milk contains very little iron, and therefore, breastfed infants should be supplemented with 1 mg/kg per day of oral iron from 4 months of age until iron-rich foods are introduced. Formula-fed infants receive adequate iron from formula and complementary foods, and supplementation is not required.
3. Which of the following laboratory findings are most consistent with anemia related to folic acid deficiency? A. Decreased MCV and decreased MCHC B. Decreased MCV and normal MCHC C. Increased MCV and normal MCHC D. Normal MCV and normal MCHC
Answer/Rationale: 3. C. Folic acid deficiency results in impaired RNA and DNA synthesis within the developing erythrocyte and the development of immature and dysfunctional enlarged RBCs (megaloblasts). Because hemoglobin synthesis is not impaired, RBCs formed in the presence of folic acid deficiency retain their normal concentration of hemoglobin (MCHC) and normal color.
30. A 20-year-old African American male was recently treated for a minor skin infection with sulfamethoxazole/trimethoprim DS twice daily for 10 days. He returns to the clinic complaining of fatigue, yellowing of his skin and eyes, and dark urine. These symptoms lead the nurse practitioner to suspect which of the following? A. G6PD deficiency B. Pernicious anemia C. Sickle cell disease D. Thalassemia
Answer/Rationale: 30. A. Glucose-6-Phosphate Dehydrogenase deficiency is a genetic disorder in which the body doesn't have enough of the G6PD enzyme to help protect the RBCs from oxidative insult. The most common presentation is hemolytic anemia, leading to symptoms of jaundice, pallor, fatigue, dark urine, tachycardia, and dyspnea. G6PD is on the X chromosome and tends to affect more men than women. The hemolytic anemia is most often triggered by an oxidative stressor such as bacterial or viral infections and certain medications (sulfonamides, analgesics, antimalarials, antihelminths). Hemolytic anemia can also occur after eating fava beans or inhaling pollen from fava plants (a reaction called favism), or exposure to mothballs.
31. The nurse practitioner is caring for the mother of three children under the age of 5 years who recently began supplementation with ferrous sulfate over-the-counter. What is the most important educational focus for her at this follow-up visit? A. Addressing the importance of taking the medication at the same time every day. B. Determining where she keeps her medication bottles. C. Ensuring that she understands the rationale for her current therapy. D. Identifying the underlying pathophysiology leading to anemia.
Answer/Rationale: 31. B. Iron poisoning is a common toxicologic emergency in young children. Education is essential in the prevention of such events. More than 15,000 cases of iron exposure are reported to poison control centers across the nation annually. Approximately 1/5 of cases result in unintentional ingestion in children under the age of 6. The medication is available in many forms, including tablets, capsules, drops, syrups, and elixirs contained in bottles both with and without child-proof closures. The availability of the medication within reach of children in the home and the candy-like appearance contributes to these avoidable occurrences.
32. A 16-year-old female is experiencing an asthma exacerbation following exposure to cats at her neighbor's home. Which leukocyte will likely be elevated? A. Basophils B. Eosinophils C. Monocytes D. Neutrophils
Answer/Rationale: 32. B. The leukocytes that increase during an allergic reaction are the eosinophils. Eosinophils regulate inflammation and destroy foreign substances. The normal percentage of eosinophils on a CBC differential is 0-5%. Eosinophilia occurs when a large amount of eosinophils are recruited to a particular site in the body and are most commonly triggered by allergic disorders and parasitic infections.
33. Which of the following conditions is a common reason for lymphocytosis? A. Acute rhinosinusitis B. Leukemia C. Malaria D. Streptococcal pharyngitis
Answer/Rationale: 33. B. The majorities of both acute and chronic forms of leukemia affect lymphocytes and are a common reason for leukocytosis. Lymphocytes are the primary components of the body's immune system and are the second most common WBCs, second to neutrophils. Lymphocytosis may also indicate acute or chronic infections, cancer of the blood or lymphatic system, or autoimmune disorders causing chronic inflammation.
34. A 33-year-old pregnant female with a history of beta thalassemia trait consults with the nurse practitioner about her child's risk for inheriting the disorder. The father of the child is uninvolved in the prenatal planning, and it is unknown whether he is a carrier. The most appropriate action by the nurse practitioner is to: A. Counsel the mother about pregnancy termination options. B. Discuss that a prenatal diagnosis cannot be made. C. Discuss that the chances of the child inheriting the disease are 50%. D. Refer the patient for genetic counseling.
Answer/Rationale: 34. D. Parents with any combination of alpha or beta thalassemia syndromes place a child at risk for the disorder. Each child of two carrier parents is at a 25% risk of the disease. If a parent is positive for the trait, a prenatal diagnosis can be made with fetal blood sampling or chorionic villi sampling. Genetic counseling is an integral and necessary component of comprehensive care for patients and parents affected by all forms of thalassemia disease and trait. Genetic counseling is the process of providing information and support to individuals and families with a diagnosis and/or risk of occurrence of an inherited disorder. Services should be provided by a licensed genetic counselor.
35. Which of the following lab tests confirms a diagnosis of iron deficiency when evaluating microcytic anemia? A. Hgb electrophoresis B. Platelet count C. Serum ferritin D. Vitamin B12 level
Answer/Rationale: 35. C. Ferritin is a protein found within cells that stores iron for later use. Serum ferritin reflects the iron storage capacity of the body and is the most useful test to diagnose iron deficiency anemia. Serum ferritin levels are often ordered in conjunction with other iron tests such as the total iron binding capacity (TIBC). Ferritin levels are low in iron deficiency anemia and elevated in iron overload, inflammation, or infection. A normal ferritin level is 12-300 ng/mL in males and 12-150 ng/mL in females.
Robin has human immunodeficiency virus (HIV) and is having a problem with massive diarrhea. You suspect the cause is: 1.Cryptococcosis. 2.Toxoplasmosis. 3.Cryptosporidiosis. 4.Cytomegalovirus.
Cryptosporidiosis.
Mrs. Jameson complains of unilateral blurry vision and partial blindness in the left eye. On physical examination, you find decreased peripheral vision on her left side. Funduscopic examination reveals cotton wool spots. Your most likely diagnosis is: 1.Cryptococcosis. 2.Toxoplasmosis. 3.Cytomegalovirus infection. 4.Herpes simplex virus infection.
Cytomegalovirus infection.
Your client George, age 60, presents with pruritus and complains of lymphadenopathy in his neck. He also complains of night sweats and has noticed a low-grade fever. He has not lost any weight and otherwise feels well. He is widowed and has been dating a new woman recently. On physical exam, you find enlarged supraclavicular nodes. You suspect: 1.Lung cancer. 2.Hodgkin lymphoma. 3.A lingering viral infection from a bout of flu he had 6 weeks ago. 4.Non-Hodgkin lymphoma.
Hodgkin lymphoma.
Which hypersensitivity reaction results in a skin test that produces erythema and edema within 3 to 8 hours? 1.Anaphylactic reaction. 2.Cytotoxic reaction. 3.Immune complex-mediated reaction. 4.Delayed hypersensitivity reaction.
Immune complex-mediated reaction.
When the donor and recipient of a transplant are identical twins, this is referred to as what type of transplant? 1.Isograft. 2.Autograft. 3.Allograft. 4.Xenograft.
Isograft.
Which of the following is a benign neoplasm? 1.Leiomyoma. 2.Osteosarcoma. 3.Glioma. 4.Seminoma
Leiomyoma.
Your client Shirley has an elevated mean corpuscular volume (MCV). What should you be considering in terms of diagnosis? 1.Iron deficiency anemias. 2.Hemolytic anemias. 3.Lead poisoning. 4.Liver disease.
Liver disease
You are examining Joseph, age 9 months, and note a palpable right supraclavicular lymph node. You know that this finding is suspicious for: 1.Candidiasis. 2.Cryptococcosis. 3.Lymphoma of the mediastinum. 4.Abdominal malignancy
Lymphoma of the mediastinum.
Tina, age 2, had a complete blood count (CBC) drawn at her last visit. It indicates that she has a microcytic hypochromic anemia. What should you do now at this visit? 1.Obtain a lead level. 2.Instruct Tina's parents to increase the amount of milk in her diet. 3.Start Tina on ferrous sulfate (Feosol) and check the CBC in 6 weeks. 4.Recheck the CBC.
Obtain a lead level.
Julie's brother has chronic lymphocytic leukemia (CLL). She overheard that he was in stage IV and asks what this means. According to the Rai classification system, stage IV is a stage: 1.In which the lymphocyte count is greater than 10,000 mm3. 2.Indicating absolute lymphocytosis, in which the client may live 7 to 10 years or more. 3.Of thrombocytopenia in which the life expectancy may be only 2 years. 4.Of anemia.
Of thrombocytopenia in which the life expectancy may be only 2 years.
Which of the following is the most common cause of megaloblastic anemia? 1.Vitamin B12 deficiency. 2.Pernicious anemia. 3.Iatrogenesis. 4.Folate deficiency.
Pernicious anemia.
Despite successful primary prophylaxis, which infection remains a common AIDS-defining diagnosis? 1.Pneumocystis jiroveci pneumonia 2.Cryptococcosis. 3.Cryptosporidiosis. 4.Candidiasis.
Pneumocystis jiroveci pneumonia
Frank, a 66-year-old white male who is on diuretic therapy, presents with an elevated hematocrit. He also has splenomegaly on examination as well as subjective complaints of blurred vision, fatigue, headache, and tinnitus. You suspect: 1.Multiple myeloma. 2.Waldenström macroglobulinemia. 3.Dehydration related to the use of diuretics. 4.Polycythemia vera.
Polycythemia vera.
Your client Jeannie, age 64, comes to you complaining of tinnitus and lightheadedness without loss of consciousness. On physical exam, you note splenomegaly. To sort out your differential diagnosis, you order an alkaline phosphatase and vitamin B12 level because you are ruling out a diagnosis of: 1.Liver cancer. 2.Pancreatic cancer. 3.Mononucleosis. 4.Polycythemia vera.
Polycythemia vera.
Which of the following diagnostic tests confirms the diagnosis of sideroblastic anemia? 1.Prussian blue stain. 2.Complete blood count (CBC). 3.Red blood cell electrophoresis. 4.Erythrocyte sedimentation rate (ESR).
Prussian blue stain.
Caroline, 65, is homeless and has iron deficiency anemia. She smokes and drinks when she can and has a stomach ulcer. Which of the following is not one of her risk factors for iron deficiency anemia? 1.Smoking. 2.Poverty. 3.Ulcer. 4.Age greater than 60.
Smoking.
Ms. Jones, your client, has an elevated platelet count. You suspect: 1.Systemic lupus erythematosus (SLE). 2.Infectious mononucleosis. 3.Disseminated intravascular coagulation (DIC). 4.Splenectomy.
Splenectomy.
