Hematological ms fall 2020

A young female client has pale nailbeds. Her hemoglobin count is 10.2 gm/dL and her hematocrit count is 30%. She reports fatigue and states, "I'm tired all the time." The client also reports excessive menstrual flow. The nurse assesses further and determines the client's diet is balanced and provides adequate calories. The client is prescribed supplemental iron therapy. The highest nursing diagnosis is

Altered tissue perfusion related to diminished oxygen-carrying capacity of the blood Explanation: All the nursing diagnoses are appropriate for this client who is experiencing anemia. Physiological needs take priority per Maslow's hierarchy of needs. Under physiological needs, airway, breathing, and then circulation take priority. Altered tissue perfusion would be classified under circulation, thus making it the priority over the other diagnoses listed.

Which nursing intervention should be incorporated into the plan of care to manage the delayed clotting process due to thrombocytopenia in a client with leukemia?

Applying prolonged pressure to needle sites or other sources of external bleeding Explanation: The interventions for a client with thrombocytopenia are the same as those for a client with cancer who is at risk for bleeding. For a client with leukemia, the nurse should apply prolonged pressure to needle sites or other sources of external bleeding. Reduced platelet production results in a delayed clotting process and increases the potential for hemorrhage. Implementing neutropenic precautions and eliminating direct contact with others are interventions to address the risk for infection.

A client is diagnosed with megaloblastic anemia caused by vitamin B12 deficiency. The health care provider begins the client on cyanocobalamin (Betalin-12), 100 mcg I.M. daily. Which substance influences vitamin B12 absorption?

Intrinsic factor Explanation: Vitamin B12 absorption depends on intrinsic factor, which is secreted by parietal cells in the stomach. The vitamin binds with intrinsic factor and is absorbed in the ileum. Hydrochloric acid, histamine, and liver enzymes don't influence vitamin B12 absorption.

A nurse is providing education to a client with iron deficiency anemia who has been prescribed iron supplements. What should the nurse include in health education?

Iron will cause the stools to darken in color. Explanation: The nurse will inform the client that iron will cause the stools to become dark in color. Iron should be taken on an empty stomach, as its absorption is affected by food, especially dairy products. Clients should be instructed to increase their intake of vitamin C to enhance iron absorption. Foods high in fiber should be consumed to minimize problems with constipation, a common side effect associated with iron therapy.

The nurse is caring for an older adult client who has a hemoglobin of 9.6 g/dL and a hematocrit of 34%. To determine where the blood loss is coming from, what intervention can the nurse provide?

Observe stools for blood. Explanation: Iron-deficiency anemia is unusual in older adults. Normally, the body does not eliminate excessive iron, causing total body iron stores to increase with age and necessitating maintenance of hydration. If an older adult is anemic, blood loss from the gastrointestinal or genitourinary tracts is suspected. Observing the stool for blood will help detect blood from GI loss. Bleeding gums may indicate periodontal disease, or anticoagulation from medication is not related to age. Blood in sputum can be an indicator of various lung disorders that may affect all age groups. Facial droop may indicate an impending stroke or Bell's palsy and would not be a reason for blood loss.

While assessing a client, the nurse will recognize what as the most obvious sign of anemia?

Pallor Explanation: On physical examination, pallor is the most common and obvious sign of anemia. Other findings may include tachycardia and flow murmurs. Patients with hemolytic anemia may exhibit jaundice and splenomegaly.

A client's blood work reveals a platelet level of 17,000/mm3. When inspecting the client's integumentary system, what finding would be most consistent with this platelet level?

Petechiae Explanation: When the platelet count drops to less than 20,000/mm3, petechiae can appear. Low platelet levels do not normally result in dermatitis, urticaria (hives), or alopecia (hair loss).

A young mother with a 2 year old and a 6 month old is experiencing fatigue related to anemia. The client states that she is having difficulty performing the activities needed for her job, family, and home. With what task is it most appropriate for the nurse to assist the client?

Prioritizing and balancing activities and rest. Explanation: Fatigue is the most common symptom and complication of anemia. The nurse should assist the client to prioritize activities and to establish a balance between activity and rest that the client finds acceptable. With the other options, the nurse is jumping to conclusions that these things will help the client.

Erythropoietin growth factor increases production of which of the following?

Red blood cells Explanation: Erythropoietin growth factor increases the production of red blood cells, thus decreasing the symptoms of anemia.

The nurse should advise a client with iron deficiency anemia to take which action in order to prevent staining of the teeth?

Use a straw or place a spoon at the back of the mouth to take the liquid supplement. Explanation: For a client with iron deficiency anemia who is taking an oral iron supplement, the nurse instructs the client to use a straw or place a spoon at the back of the mouth to take the liquid supplement to avoid staining the teeth. The nurse advises the client to take iron with or immediately after meals to avoid gastric distress. The client is advised to avoid having iron simultaneously with an antacid, as the antacid will interfere with iron absorption.

A client was diagnosed with pernicious anemia. Which vitamin cannot be absorbed without an intrinsic factor?

Vitamin B12 Explanation: Vitamin B12 needs to be absorbed in the ileum, where the pH is higher than in the stomach. This vitamin is transported by a glycoprotein known as intrinsic factor.

A client comes into the emergency department reporting an enlarged tongue. The tongue appears smooth and beefy red in color. The nurse also observes a 5-cm incision on the upper left quadrant of the abdomen. When questioned, the client states, "I had a partial gastrostomy 2 years ago." Based on this information, the nurse attributes these symptoms to which problem?

Vitamin B12 deficiency Explanation: Because vitamin B12 is found only in foods of animal origin, strict vegetarians may ingest little vitamin B12. Vitamin B12 combines with intrinsic factor produced in the stomach. The vitamin B12-intrinsic factor complex is absorbed in the distal ileum. Clients who have had a partial or total gastrectomy may have limited amounts of intrinsic factor, and therefore the absorption of vitamin B12 may be diminished. The effects of either decreased absorption or decreased intake of vitamin B12 are not apparent for 2-4 years. This results in megaloblastic anemia. Some symptoms are a smooth, beefy red, enlarged tongue and cranial nerve deficiencies.

A client is admitted to the hospital with an exacerbation of chronic gastritis. When assessing the client's nutritional status, the nurse should expect to find what type of deficiency?

vitamin B12 Explanation: The nurse should expect vitamin B12 deficiency. Injury to the gastric mucosa causes gastric atrophy and impaired function of the parietal cells. These changes result in reduced production of intrinsic factor, which is necessary for the absorption of vitamin B12. Eventually, pernicious anemia will occur. Deficiencies in vitamins A, B6, and C aren't expected in a client with chronic gastritis.

The patient diagnosed with thrombocytopenia is at risk for which of the following adverse effects

Bleeding Explanation: The patient diagnosed with thrombocytopenia is at risk for bleeding and infection until blood cell counts return to normal. Headache, diminished reflexes, and stomatitis are not adverse effects related to the diagnosis.

The nurse should advise a client with iron deficiency anemia to take which action in order to prevent staining of the teeth?

Dilute liquid preparations of iron with juice and drink with a straw Explanation: For a client with iron deficiency anemia who is taking an oral iron supplement, the nurse instructs the client to dilute liquid preparations of iron with another liquid, such as juice, and drink with a straw to avoid staining the teeth. The nurse advises the client to take iron with or immediately after meals to avoid gastric distress. The client is advised to avoid taking iron simultaneously with an antacid, as the antacid will interfere with iron absorption.

The nurse is caring for a client with external bleeding. What is the nurse's priority intervention?

Direct pressure Explanation: Applying direct pressure to an injury is the initial step in controlling bleeding. Elevation reduces the force of flow, but direct pressure is the first step. The nurse may use pressure point control for severe or arterial bleeding. Pressure points (those areas where large blood vessels can be compressed against bone) include femoral, brachial, facial, carotid, and temporal artery sites. The nurse should avoid applying a tourniquet unless all other measures have failed, because it may further damage the injured extremity.

When assessing a client with anemia, which assessment is essential?

Health history, including menstrual history in women Explanation: When assessing a client with anemia, it is essential to assess the client's health history. Women should be questioned about their menstrual periods (e.g., excessive menstrual flow, other vaginal bleeding) and the use of iron supplements during pregnancy.

When assessing a client with a disorder of the hematopoietic or the lymphatic system, which assessment is most essential?

Health history, such as bleeding, fatigue, or fainting Explanation: When assessing a client with a disorder of the hematopoietic or the lymphatic system, it is essential to assess the client's health history. An assessment of drug history is essential because some antibiotics and cancer drugs contribute to hematopoietic dysfunction. Aspirin and anticoagulants may contribute to bleeding and interfere with clot formation. Because industrial materials, environmental toxins, and household products may affect blood-forming organs, the nurse needs to explore exposure to these agents. Menstrual history, age, gender, and lifestyle assessments, such as exercise routines and habits, do not directly affect the hematopoietic or lymphatic system.

A client has been diagnosed with pernicious anemia. During client education, the nurse emphasizes the importance of lifelong intramuscular administration of:

vitamin B12. Explanation: For a client with pernicious anemia, the nurse emphasizes the importance of lifelong administration of vitamin B12. He or she teaches the client or a family member of the proper method to administer vitamin B12 injections.

The nurse is collecting data for a client who has been diagnosed with iron-deficiency anemia. What subjective findings does the nurse recognize as symptoms related to this type of anemia?

"I have difficulty breathing when walking 30 feet." Explanation: Most clients with iron-deficiency anemia have reduced energy, feel cold all the time, and experience fatigue and dyspnea with minor physical exertion. The heart rate usually is rapid even at rest. The CBC and hemoglobin, hematocrit, and serum iron levels are decreased. The client would feel cold and not hot. The client is fatigue and able to sleep often with a decrease in appetite, not an increase.