Ch 31 *

The nurse is admitting a client with Cooley's anemia to the hospital with a hemoglobin of 6.2 g/dL and hematocrit of 26%. What does the nurse document about the client's skin? A) Bronzing of the skin B) Jaundice of the skin and mucous membranes C) Ruddy complexion D) Pale skin and mucous membranes

Ans: A Feedback:Clients with Cooley's anemia, a severe form of beta-thalassemia, exhibit symptoms of severe anemia and a bronzing of the skin caused by hemolysis of erythrocytes. The client is not jaundice, ruddy, or pale with this disorder.

The nurse is instructing the client with polycythemia vera how to perform isometric exercises such as contracting and relaxing the quadriceps and gluteal muscle during periods of inactivity. What does the nurse understand is the rationale for this type of exercise? A) Isometric exercise programs are inclusive of all muscle groups and have an aerobic effect to increase the heart rate. B) Isometric exercise decreases the workload of the heart and restores oxygenated blood flow. C) This type of exercise increases arterial circulation as it returns to the heart. D) Contraction of skeletal muscle compresses the walls of veins and increases the circulation of venous blood as it returns to the heart.

Ans: D Feedback:Isometric exercise induce contraction of skeletal muscle so that it compresses the walls of veins and increases the circulation of venous blood as it returns to the heart. Isometric exercises do not have an aerobic effect and should not increase the heart rate; although, it may increase blood pressure. Isometric exercise does not decrease the workload of the heart. Arterial flow moves blood flow away from the heart after being oxygenated.

You are assisting your client with multiple myeloma to ambulate. What is the most important nursing diagnosis to help prevent fractures in this client? A) Increased mobility B) Adequate hydration C) Safety D) Adequate nutrition

Ans: C Feedback:Safety is paramount because any injury, no matter how slight, can result in a fracture.

The nurse observes the laboratory studies for a client in the hospital with fatigue, feeling cold all of the time, and hemoglobin of 8.6 g/dL and a hematocrit of 28%. What finding would be an indicator of iron-deficiency anemia? A) Erythrocytes that are microcytic and hypochromic B) Erythrocytes that are macrocytic and hyperchromic C) Clustering of platelets with sickled red blood cells D) An increased number of erythrocytes

Ans: A Feedback:A blood smear reveals erythrocytes that are microcytic (smaller than normal) and hypochromic (lighter in color than normal). It does not reveal macrocytic (larger than normal) or hyperchromic erythrocytes. Clustering of platelets with sickled red blood cells would indicate sickle cell anemia. An increase in the number of erythrocytes would indicate polycythemia vera.

The nurse is caring for a client who is having a sickle cell crisis. Which order for analgesia should the nurse consult with the physician? A) Meperedine (Demerol) B) Morphine sulfate C) Sublimaze (Fentanyl) D) Buprenorphine (Buprenex)

Ans: A Feedback:Consult the physician if meperidine (Demerol) is prescribed for treating pain in clients with sickle cell crisis. The liver converts meperidine to normeperidine, which is toxic. Grand mal seizures can result. The other medications are acceptable alternatives to Demerol.

The nurse is instructing the client with sickle cell disease about the use of an inhaled vasodilator that may reduce sickling. What medication is the nurse instructing the client about? A) Nitrous oxide B) Nitric oxide C) Betamethasone D) Terbutaline (Brethine)

Ans: B Feedback:Inhaled nitric oxide—not nitrous oxide (laughing gas), a vasodilating agent—is believed to reduce sickling by promoting the binding of oxygen to hemoglobin. It is being used in the form of handheld inhalers to abort or relieve pain experienced during sickle cell crises. Betamethasone is a corticosteroid, and terbutaline is not used as an inhaler.

A client with multiple myeloma is complaining of severe pain when the nurse comes in to give a bath and change position. What is the priority intervention by the nurse? A) Inform the client that the position must be changed, and then you will give her pain medication and omit the bath. B) Inform the client that she will feel better after receiving a bath and clean sheets. C) Obtain the pain medication and delay the bath and position change until the medication reaches its peak. D) Inform the client that the bath and positioning is an important part of client care and will be done right after pain medication administration.

Ans: C Feedback:When pain is severe, the nurse delays position changes and bathing until an administered analgesic has reached its peak concentration level and the client is experiencing maximum pain relief. Pain medication should never be delayed to assist in the control of the level of pain. Pain will not be relieved by a bath and clean sheets, only analgesics at this point in the client's illness.

The nursing instructor is talking with her clinical group about coagulopathies. How should the instructor define coagulopathies? A) Coagulopathies are bleeding disorders that are characterized by abnormalities in the numbers and types of red blood cells in the body. B) Coagulopathies are bleeding disorders that involve platelets or clotting factors. C) Coagulopathies are bleeding disorders that are characterized by a deficiency of globulins in the plasma. D) Coagulopathies are bleeding disorders that involve the destruction of stem cells in the bone marrow.

Ans: B Feedback: Coagulopathies are bleeding disorders that involve platelets or clotting factors. Coagulopathies do not involve the numbers and types of red blood cells. They are not characterized by a deficiency of globulins in the plasma, and they do not involve the destruction of stem cells in the bone marrow.

A client with a diagnosis of pernicious anemia comes to the clinic complaining of numbness and tingling in his arms and legs. What do these symptoms indicate? A) Loss of vibratory and position senses B) Neurologic involvement C) Severity of the disease D) Insufficient intake of dietary nutrients

Ans: B Feedback:In clients with pernicious anemia, numbness and tingling in the arms and legs and ataxia are the most common signs of neurologic involvement. Some affected clients lose vibratory and position senses. Jaundice, irritability, confusion, and depression are present when the disease is severe. Insufficient intake of dietary nutrients is not indicated by these symptoms.

The nurse is caring for a client with hypovolemic anemia who is now in hypovolemic shock. What indication does the nurse have that the client is having inadequate renal perfusion? A) Hematuria B) Blood pressure of 90/60 mm Hg C) Jaundice of the sclera D) Urine output of 15 mL/hour

Ans: D Feedback:Urine output of less than 30 to 50 mL/hour reflects inadequate renal perfusion. The kidneys must excrete 30 to 50 mL/hour or 500 mL/24 hours to eliminate wastes sufficiently. Hematuria is an indicatory of other problems such as hemorrhagic cystitis, trauma to the bladder, etc. It is not an indicator of renal perfusion. A blood pressure of 90/60 mm Hg does not indicate that the client is having a decrease in renal perfusion nor does jaundice. Jaundice is present when the liver starts to fail.

The nursing instructor is discussing disorders of the hematopoietic system with the pre-nursing pathophysiology class. What disease would the instructor list with a primary characteristic of erythrocytosis? A) Polycythemia vera B) Sickle cell disease C) Aplastic anemia D) Pernicious anemia

Ans: A Feedback:Polycythemia vera is associated with a rapid proliferation of blood cells produced by the bone marrow. In sickle cell disease, HbS causes RBCs to assume a sickled shape under hypoxic conditions. Aplastic anemia has a deficiency of erythrocytes. Options B, C, and D do not have the characteristics of erythrocytosis.

Parents arrive to the clinic with their 5-year-old child and inform the nurse the child has just been diagnosed with sickle cell disease. The parents ask the nurse how this could have happened and which one of them is the carrier. What is the best response by the nurse? A) "Most likely, the father is the carrier of the gene." B) "The trait is passed down through the mother." C) "The child must inherit two defective genes, one from each parent." D) "It is an acquired, not a hereditary disorder."

Ans: C Feedback:Sickle cell disease is a hereditary disorder. To manifest this disorder, a person must inherit two defective genes, one from each parent, in which case all the hemoglobin is inherently abnormal. If the person inherits only one gene, he or she carries sickle cell trait. The hemoglobin of those who have sickle cell trait is about 40% affected. The other distractors are incorrect due to these factors.

The nurse is caring for a client who is developing hypovolemic shock from a duodenal ulcer bleed. What is the first intervention the nurse can provide to facilitate blood flow to the brain? A) Prepare the client for an endoscopy. B) Administer a crystalloid solution. C) Place the client in a modified Trendelenburg position. D) Test the client for blood in the stool.

Ans: C Feedback:The first action by the nurse would be to place the client in a modified Trendelenburg position to facilitate blood flow to the brain. Administering a crystalloid solution and testing the client for blood in the stool may be later action but is not relevant in facilitating blood flow to the brain. Preparing the client for an endoscopy would be important after the physician obtains the informed consent but would not facilitate blood flow to the brain.

Your client was admitted to the emergency department after an accident with a chain saw. The client is exhibiting signs and symptoms of acute hypovolemic anemia from severe blood loss. What signs and symptoms would you assess for? A) Malabsorption disorders B) Postural hypotension C) Fatigue D) Reduced urine output

Ans: D Feedback: Acute hypovolemic anemia from severe blood loss is evidenced by the signs and symptoms of hypovolemic shock, which include reduced urine output. The symptoms of chronic hypovolemic anemia include fatigue and postural hypotension. Clients with malabsorption disorders are at great risk of iron-deficiency anemia.

A client diagnosed with polycythemia vera has come into the clinic because he has developed a nighttime cough, fatigue, and shortness of breath. What complication would you suspect in this client? A) Stroke B) Tissue infarction C) Congestive heart failure D) Pulmonary embolus

Ans: C Feedback:The symptoms exhibited by this client are indicative of congestive heart failure. Complications include hypertension, congestive heart failure, stroke, tissue and organ infarction, and hemorrhage. Stroke would present with headache, aphasia, and/or numbness in extremities. Tissue infarction would involve extremity discoloration or an organ failure. Pulmonary embolism would be associated with chest pain.

A client was admitted to the hospital with a pathologic pelvic fracture. The client informs the nurse that he has been having a strange pain in the pelvic area for a couple of weeks that was getting worse with activity prior to the fracture. What does the nurse suspect may be occurring based on these symptoms? A) Hemolytic anemia B) Polycythemia vera C) Leukemia D) Multiple myeloma

Ans: D Feedback:The first symptom usually is vague pain in the pelvis, spine, or ribs. As the disease progresses, the pain becomes more severe and localized. The pain intensifies with activity and is relieved by rest. When tumors replace bone marrow, pathologic fractures develop. Hemolytic anemia does not result in pathologic fractures nor does polycythemia vera or leukemia.

A client comes to the walk-in clinic complaining of weakness and fatigue. While assessing this client, you find evidence of petechiae and ecchymoses. You note that the spleen appears enlarged. What would you suspect is wrong with this client? A) Aplastic anemia B) Pernicious anemia C) Iron-deficiency anemia D) Agranulocytosis

Ans: A Feedback:Clients with aplastic anemia experience all the typical characteristics of anemia (weakness and fatigue). In addition, they have frequent opportunistic infections plus coagulation abnormalities that are manifested by unusual bleeding, small skin hemorrhages called petechiae, and ecchymoses (bruises). The spleen becomes enlarged with an accumulation of the client's blood cells destroyed by lymphocytes that failed to recognize them as normal cells, or with an accumulation of dead transfused blood cells. The blood cell count shows insufficient numbers of blood cells. A bone marrow aspiration confirms that the production of stem cells is suppressed. This scenario does not describe a client with pernicious anemia, iron-deficiency anemia, or agranulocytosis.

The nurse is collecting data for a patient who has been diagnosed with iron-deficiency anemia. What subjective findings does the nurse recognize as symptoms related to this type of anemia? A) "I feel hot all of the time." B) "I have a difficult time falling asleep at night." C) "I have an increase in my appetite." D) "I have difficulty breathing when walking 30 feet."

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

The nurse caring for an older adult with a diagnosis of leukemia would encourage the client to use an electric razor. Why? A) Trauma and micro abrasions may contribute to anemia. B) Fragile tissues and altered clotting mechanisms may result in hemorrhage. C) The client is at risk for spontaneous and uncontrolled bleeding. D) The client is at risk for infection from microorganisms.

Ans: A Feedback:In a client with leukemia who is at risk for hemorrhage, the nurse handles the client gently when assisting and encourages the client to use electric razors. Trauma and microabrasions from razors may contribute to anemia from bleeding. Fragile tissues and altered clotting mechanisms may result in hemorrhage even after minor trauma. Therefore, the nurse inspects the skin for signs of bruising and petechiae and reports melena, hematuria, or epistaxis (nosebleeds). The risks for spontaneous and uncontrolled bleeding or infection from microorganisms are not addressed by the use of electric razors.

The nurse is assigned to care for a client with polycythemia vera. When the nurse encourages the client to drink 3 L of fluid per day, the client states, "Why do I have to drink so much?" What is the best response by the nurse? A) "We don't want you to get dehydrated." B) "It helps adequately hydrate you and ensures a sufficient urine production." C) "It will help your heart beat regularly and effectively." D) "It will help restrict blood circulation."

Ans: B Feedback:The client should be advised to drink 3 quarts (or liters) per day. Adequate hydration promotes venous return and ensures sufficient urine production. Informing the client that the healthcare team does not want them to get dehydrated does not address the rationale that the client requires. Fluid hydration will not help the heart beat regularly or more effectively and it will not help to restrict blood circulation.

The nurse is caring for an older adult client who has a hemoglobin of 9.6 g/dL and a hematocrit of 34%. To determine where the blood loss is coming from, what intervention can the nurse provide? A) Observe stools for blood. B) Observe the gums for bleeding after the client brushes teeth. C) Observe the sputum for signs of blood. D) Observe client for facial droop.

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

A client is experiencing chronic hypovolemic anemia as evidenced by laboratory results. What symptoms does the nurse expect to find for this client when collecting objective data? A) Postural hypotension B) Urinary output of 10 mL/hr C) Altered consciousness D) Extreme pallor

Ans: A Feedback:Symptoms of chronic hypovolemic anemia include pallor, fatigue, chills, postural hypotension, and rapid heart rate and respiratory rates. The symptom of decreased urinary output, altered consciousness, and extreme pallor are all signs of acute hypovolemic anemia from severe blood loss. These signs indicate hypovolemic shock.

A 15-year-old client with hemophilia sustains a leg laceration after falling off of his skateboard and is brought to the emergency department. The laceration is bleeding profusely even with direct pressure to the site. What does the nurse anticipate will be ordered for administration to control bleeding? A) Fresh frozen plasma B) A colloid solution such as hetastarch (Hespan) C) A crystalloid solution such as lactated Ringer's D) Albumin

Ans: A Feedback:Treatment includes transfusion of fresh blood, frozen plasma, factor VIII concentrate, and anti-inhibitor coagulant complex for hemophilia A, factor IX concentrate for hemophilia B, factor XI for hemophilia C, and the application of thrombin or fibrin to the bleeding area. Other measures used to help control bleeding are the administration of fresh frozen plasma, aminocaproic acid (Amicar) that helps to hold a clot in place once it has formed, direct pressure over the bleeding site, and cold compresses or ice packs. Hespan, lactated Ringer's, or albumin will not control the bleeding related to hemophilia.

The registered nurse (RN) and licensed practical nurse (LPN) are preparing an educational program for clients who may be at risk for the development of iron-deficiency anemia. Which clients would receive the greatest benefit from this program? Select all that apply. A) A young female client with bulimia nervosa B) An older adult client on a fixed income C) A client with Crohn's disease D) A client who lives in a nursing home E) A client who is a vegetarian

Ans: A, B, C Feedback:Those who consume a healthy diet absorb less than 10% of the iron in food. Clients whose nutrition is compromised by unhealthy dieting or who cannot afford to eat a healthy diet, lack knowledge about nutrition, or have malabsorption disorders are at great risk for iron-deficiency anemia. A young female client with bulimia nervosa has an unhealthy diet. An older adult client on a fixed income may not have the funds to eat a healthy diet. A client with Crohn's disease has a malabsorption syndrome. A client who resides in a nursing home has prepared meals as well as available supplements if required. A client who is a vegetarian is still able to receive ample iron supplementation in the vegetables being eaten.

A client is being treated in the hospital for hypovolemia related to a bleeding peptic ulcer. The nurse obtains a blood pressure reading of 88/62 mm Hg, heart rate of 112 beats/minute, and a respiratory rate of 24 breaths/minute. What is the first action by the nurse? A) Administer blood. B) Notify the physician. C) Insert two large-bore intravenous catheters. D) Administer a colloid solution.

Ans: B Feedback:A systolic blood pressure below 90 mm Hg and heart rate above 100 beats/minute should be reported immediately. Administering blood, inserting two large-bore IV catheters, and administration of a colloid solution should be performed only with a physician's order and may not be required at this time.

The nurse is caring for an older adult client with hemolytic anemia. What does the nurse understand about the reason this client is most susceptible to this disorder? A) The client is older and is probably noncompliant with medications. B) Older adult clients often take more medications than younger people. C) Older adult clients have more incidences of coagulation disorders. D) The older adult client does not follow up with physician appointments.

Ans: B Feedback:Older adults are particularly susceptible to drug-induced hemolytic anemia because they often take more drugs than younger people. Discontinuing the offending drug usually corrects the anemia. The assumption that because a client is older and probably noncompliant is incorrect. Older clients are more susceptible to gastrointestinal and genitourinary bleeding but not coagulation disorders. The older adult client does not lack follow-up with physicians more than other populations.

The nurse is caring for four clients on the medical-surgical unit of the hospital. What client is mostly likely to be receiving treatment for sickle cell crisis? A) A 29-year-old Caucasian female B) A 19-year-old African American male C) A 24-year-old Native American female D) A 36-year-old Eastern European female

Ans: B Feedback:Sickle cell disease is a common genetic disorder found primarily in African Americans but also in people from Mediterranean and Middle Eastern countries. It is unlikely that a Caucasian female, Native American female, or eastern European female will be affected by this disease.

You are caring for a client with multiple myeloma. Why would it be important to assess this client for fractures? A) Osteopathic tumors destroy bone causing fractures. B) Osteoclasts break down bone cells so pathologic fractures occur. C) Osteolytic activating factor weakens bones producing fractures. D) Osteosarcomas form producing pathologic fractures.

Ans: B Feedback:The abnormal plasma cells proliferate in the bone marrow, where they release osteoclast-activating factor. This, in turn, causes osteoclasts to break down bone cells, resulting in increased blood calcium and pathologic fractures. The plasma cells also form single or multiple osteolytic (bone-destroying) tumors that produce a "punched-out" or "honeycombed" appearance in bones such as the spine, ribs, skull, pelvis, femurs, clavicles, and scapulae. Weakened vertebrae lead to compression of the spine accompanied by significant pain. Options A, C, and D are distractors for this question.

A client is found to have a low hemoglobin and hematocrit when laboratory work was performed. What does the nurse understand the anemia may have resulted from? Select all that apply. A) Infection B) Blood loss C) Abnormal erythrocyte production D) Destruction of normally formed red blood cells E) Inadequate formed white blood cells

Ans: B, C, D Feedback:Most anemias result from (1) blood loss, (2) inadequate or abnormal erythrocyte production, or (3) destruction of normally formed red blood cells. The most common types include hypovolemic anemia, iron-deficiency anemia, pernicious anemia, folic acid deficiency anemia, sickle cell anemia, and hemolytic anemias. Although each form of anemia has unique manifestations, all share a common core of symptoms. Anemia does not result from infection or inadequate formed white blood cells.

The LPN is following a plan of care for a client who is being treated for hypovolemic anemia and is at risk for hypovolemic shock. The nurse assesses vital signs and O2 saturation and observes the saturation at 89% for 3 minutes. What should the first action by the nurse be? A) Notify the charge nurse. B) Prepare to assist with intubation. C) Give oxygen per nasal cannula D) Place the client in the supine position.

Ans: C Feedback:An expected outcome for the client with hypovolemic anemia is to monitor to detect hypoxemia and manage and minimize inadequate oxygenation. The oxygen saturation should be monitored to measure the percentage of oxygen bound to hemoglobin. The nurse should report a sustained oxygen saturation value below 90%. Give oxygen per nasal cannula or simple mask to maintain oxygen saturation at or above 90%. It is important to administer the oxygen first and then contact the charge nurse to alert them. It is not necessary at this time if the client is not in respiratory distress to intubate the client. Placing the client in the supine position would decrease the oxygen saturation level further.

The nurse is instructing a client about taking a liquid iron preparation for the treatment of iron-deficiency anemia. What should the nurse include in the instructions? A) Do not take medication with orange juice because it will delay absorption of the iron. B) Iron may cause indigestion and should be taken with an antacid such as Mylanta. C) Dilute the liquid preparation with another liquid such as juice and drink with a straw. D) Discontinue the use of iron if your stool turns black.

Ans: C Feedback:Dilute liquid preparations of iron with another liquid such as juice and drink with a straw to avoid staining the teeth. Avoid taking iron simultaneously with an antacid, which interferes with iron absorption. Drink orange juice or take other forms of vitamin C with iron to promote its absorption. Expect iron to color stool dark green or black.

A client with sickle cell disease informs the nurse that he is having chest pain. The nurse hears the client coughing, wheezing, and breathing rapidly. What does the nurse suspect is occurring with this client? A) Vaso-occlusive crisis B) Pneumocystis pneumonia C) Acute chest syndrome D) Acute muscular strain

Ans: C Feedback:One of the unique manifestations of sickle cell disease is "acute chest syndrome," a type of pneumonia triggered by decreased hemoglobin and infiltrates in the lungs. Acute chest syndrome is characterized by respiratory symptoms, such as coughing, wheezing, tachypnea, and chest pain. Vaso-occlusive crisis causes decrease in tissue perfusion and predisposes the client to pneumonia but is not the present problem with this client. Pneumocystis pneumonia is present in the client with HIV/AIDS or other immunocompromised clients. The client's symptoms do not correlate with a diagnosis of acute muscular strain.

A client is suspected of having leukemia and is having a series of laboratory and diagnostic studies performed. What does the nurse recognize as the hallmark signs of leukemia? Select all that apply. A) Diarrhea B) Nausea and vomiting C) Frequent infections D) Fatigue from anemia E) Easy bruising

Ans: C, D, E Feedback:Infections, fatigue from anemia, and easy bruising are hallmarks of leukemia. At the onset of leukemia, particularly in acute lymphocytic leukemia (ALL), a fever is present, the spleen and lymph nodes enlarge, and internal or external bleeding develops. Diarrhea and nausea and vomiting are not the hallmark signs of leukemia and can be indicators in many illnesses and gastrointestinal disorders.

You are caring for an 87-year-old female who has been admitted to your unit with anemia. What would you suspect? A) Excessive consumption of coffee or tea B) Elimination of iron by the body C) Decrease in the total body iron stores with age D) Blood loss from the gastrointestinal or genitourinary tract

Ans: D Feedback:If an older adult is anemic, blood loss from the gastrointestinal or genitourinary tract is suspected. This is because iron-deficiency anemia is unusual in older adults as the body does not eliminate excessive iron, causing total body iron stores to increase with age. Excessive consumption of coffee or tea is not a causative factor for anemia in older adults.

A client is seen in the emergency department with severe pain related to a sickle cell crisis. What does the nurse understand is occurring with this client? A) The client has a decreased tolerance of pain related to the chronic nature of the illness. B) Bone marrow decreases the erythrocyte production causing decrease in hypoxia. C) Over-hydration enlarges the red blood cells. D) Vascular occlusion in small vessels decreasing blood and oxygen to the tissues.

Ans: D Feedback:The person with sickle cell disease repeatedly suffers from two major problems: (1) episodes of sickle cell crisis from vascular occlusion, which develops rapidly under hypoxic conditions, and (2) chronic hemolytic anemia. During a sickle cell crisis, the sickle-shaped cells lodge in small blood vessels, where they block the flow of blood and oxygen to the affected tissue. The vascular occlusion induces severe pain in the ischemic tissue. The client may have increased tolerance for pain due to the chronic nature of the illness. Bone marrow increases the erythrocyte production. Underhydration increases the client's risk of developing a vaso-occlusive crisis.