PrepU Chapters 21-24, 29-31
The neonate displays a yellow discoloration of her skin on the second day of life. The neonatologist explains this condition to the parents. Which statement is most accurate?
"The increase in bilirubin, which causes the jaundice, is related to the increased red blood cell breakdown." Explanation: Physiologic jaundice appears in term infants on the second or third day of life. The increase in bilirubin is related to the increased red cell breakdown and the inability of the immature liver to conjugate bilirubin. Many factors cause elevated bilirubin levels in the neonate, including breast-feeding. Hyperbilirubinemia places the neonate at risk for development of a neurologic syndrome called kernicterus. Most neonatal jaundice resolves spontaneously within 1 week.
Which person should the charge nurse assign as a roommate for a client diagnosed with aplastic anemia?
A client in traction with a broken femur Explanation: Aplastic anemia develops when the multipotent stem cells fail to grow and provide cells for differentiation. The result is concomitant anemia, thrombocytopenia, and granulocytopenia (pancytopenia). Clients with aplastic anemia are at risk for infection because of the low white blood cell production. The nurse should avoid assigning a roommate with any possible infectious process.
The nursing is reviewing assessment data of four clients. Which client is at greatest risk for developing pernicious anemia?
A client who has undergone partial gastrectomy Explanation: Pernicious anemia results from vitamin B12 deficiency. Vitamin B12 is absorbed by a unique process. After release from the animal protein, it is bound to intrinsic factor, a protein secreted by the gastric parietal cells. Causes of this anemia include gastrectomy, ileal resection, inflammation or neoplasms in the terminal ileum, and malabsorption syndromes in which vitamin B12 and other B-vitamin compounds are poorly absorbed. The other options will not cause pernicious anemia.
Which is considered a component(s) of blood? Select all that apply.
plasma erythrocytes platelets eosinophils Explanation: Blood is made up of plasma and the formed elements (blood cells). The blood cells include erythrocytes (red blood cells), thrombocytes (platelets), and all the various leukocytes (white blood cells). Eosinophils are one type of leukocyte, so they are a component of blood. Within the plasma are proteins and substances such as hormones, enzymes, electrolytes, and byproducts of cellular waste. Ascites is an accumulation of intraperitoneal fluid containing large amounts of protein and electrolytes. Although most blood cells are derived from pluripotent stem cells, these cells are not part of blood.
Anticoagulant drugs prevent thromboembolic disorders. How does warfarin, one of the anticoagulant drugs, act on the body?
Alters vitamin K, reducing its ability to participate in the coagulation of the blood Explanation: The anticoagulant drugs warfarin and heparin are used to prevent thromboembolic disorders, such as deep vein thrombosis and pulmonary embolism. Warfarin acts by decreasing prothrombin and other procoagulant factors. It alters vitamin K in a manner that reduces its ability to participate in synthesis of the vitamin K-dependent coagulation factors in the liver.
The globulins that make up part of the plasma of the blood have three distinct purposes. What are the gamma globulins?
Antibodies of the immune system Explanation: There are three types of globulins: the alpha globulins that transport bilirubin and steroids, the beta globulins that transport iron and copper, and the gamma globulins that constitute the antibodies of the immune system. Alpha globulins transport bilirubin and steroids. Beta globulins transport iron and copper. Autoantibodies are immunoglobulins that recognize an antigen on that person's own tissue.
For which health problem is stem cell transplantation likely to be of therapeutic benefit?
Aplastic anemia Explanation: The etiology of aplastic anemia involves depression of the bone marrow, a problem that can sometimes be treated by stem cell transplantation. Polycythemia, alpha-thalassemia, and anemias caused by chronic diseases are not amenable to stem cell transplantation. Beta-thalassemia (not alpha) has a potential to be cured from stem cell transplantation.
A nurse is preparing her client for a blood transfusion. She knows that a client with type A blood is said to have which type of antibodies?
B Explanation: Persons with type A antigens on their red cells develop type B antibodies; persons with type B antigens develop type A antibodies in their sera; people with type O blood develop type A and type B antibodies; and people with type AB blood develop neither A nor B antibodies.
A client comes to the clinic following exposure to chicken pox. The client states he had chickenpox as a child but was worried about getting sick again. Which statement best explains humoral-mediated immunity to the client?
B lymphocytes (B cells) in the body produce antibodies to fight infections. Once exposed, the cells retain memory and are able to quickly fight off pathogens during re-exposure and prevent the disease from reoccurring. Explanation: The B lymphocytes (B cells) differentiate to form antibody-producing plasma cells that retain memory and are involved in humoral-mediated immunity.
Pernicious anemia is thought to be an autoimmune disease that destroys the gastric mucosa. This results in chronic atrophic gastritis and the production of antibodies that interfere with which vitamin's ability to bind to intrinsic factor?
B12 Explanation: Pernicious anemia is believed to result from immunologically mediated, possibly autoimmune, destruction of the gastric mucosa. The resultant chronic atrophic gastritis is marked by loss of parietal cells and production of antibodies that interfere with binding of vitamin B12 to intrinsic factor. Folate, vitamin C, and B6 all have different methods of absorption.
Which type of white blood cells are related to the connective tissue mast cells and respond in allergic and hypersensitivity reactions?
Basophils Explanation: The basophil is related to connective tissue mast cells because they contain similar granules and are believed to be involved in allergic and hypersensitivity reactions. Neutrophils, granulocytes, and B lymphocytes are not identified as being similar to mast cells.
A client is diagnosed with an iron deficiency. When the nurse is reviewing plasma protein levels, which protein would the nurse evaluate that could contribute to a decrease in the iron-carrying capacity of the plasma?
Beta globulins Explanation: Plasma proteins are the most abundant solutes in plasma. Beta globulins transport iron and copper.
The nurse is caring for a client with leukemia who is having difficulty with blood clotting after having several transfusions with packed red blood cells. What does the nurse anticipate infusing for this client to assist with controlling the bleeding?
Platelets Explanation: Thrombocytes, or platelets, are circulating cell fragments of the large megakaryocytes that are derived from the myeloid stem cell. They function to form the platelet plug to help control bleeding after injury to a vessel wall. Their cytoplasmic granules release mediators required for the blood coagulation process. Thrombocytes have a membrane but no nucleus, cannot replicate, and, if not used, last approximately 10 days in the circulation before the phagocytic cells of the spleen remove them.
A nurse working in an ambulatory care unit is working with a client who has recently been diagnosed with a V Leiden mutation. The nurse tells the client the importance of smoking cessation to avoid:
Deep vein thrombosis (DVT) Explanation: Factor V Leiden mutation increases the risk of DVT because physiologic anticoagulants have an increased difficulty inactivation of the mutated factor V gene. The inability to inactivate the factor V Leiden gene contributes to an increase in thrombotic complications, including DVT.
The nurse is teaching a client about how a vaccine can help create immunity to a virus. What information does the nurse provide?
The vaccine causes B lymphocytes to create antibodies against the virus. Explanation: The B lymphocytes differentiate to form antibody-producing plasma cells and are involved in humoral-mediated immunity. These are the cells that, when exposed to the modified form of a virus in the form of a vaccine, will create antibodies. T lymphocytes are involved in cell-mediated immunity. The vaccine neither changes the DNA of white blood cells nor does it lay dormant in the body or fight a virus directly.
A client has an impaired platelet function that may have developed from inheritance, drugs, disease, or extracorporeal circulation. The health care provider would document this as:
Thrombocytopathy Explanation: Thrombocytopathy results from inherited disorders of adhesion and/or acquired defects such as drugs, disease process, or extracorporeal circulation. Plasmapheresis is the process of removal of plasma from withdrawn blood and replacement with fresh frozen plasma. Fibrinolysis is the process in which a blood clot is dissolved.
A nurse is assessing a client and finds these results: Areas of bruising (purpura) on the client's arms and legs Pinpoint hemorrhages (petechiae) on the legs Pinpoint hemorrhages (petechiae) in the mouth Platelets level of 90,000/μL (90 ×109/L) What condition should the nurse suspect the client is exhibiting?
Thrombocytopenia Explanation: Thrombocytopenia refers to a decrease in the number of circulating platelets to a level less than 150,000/μL(150 ×109/L). Cutaneous bleeding is seen as purple areas of bruising (purpura) and pinpoint hemorrhages (petechiae) in dependent areas where the capillary pressure is higher. Leukopenia is a decrease in white blood cells. Neutropenia is a decrease in neutrophils. Thrombocytosis describes elevations in the platelet count.
A nurse is treating a client with aplastic anemia. Due to the replacement of normal bone marrow with malignant cells, the nurse teaches the client to prevent scratches, scrapes, and cuts. What root cause likely underlies the client's increased risk for hemorrhage?
Thrombocytopenia Explanation: Thrombocytopenia results from a decrease in megakaryocytes due to overcrowding of the bone marrow. With fewer megakaryocytes the client will have fewer circulating platelets and will be at risk for bleeding. Polycythemia is an overproduction of red blood cells. Neutrophilia results from stimulation of the inflammatory system. DIC does not result from aplastic anemia.
A 53-year-old man presents with inability to concentrate, itching in his fingers and toes, elevated blood pressure, and unexplained weight loss. He is diagnosed with primary polycythemia. The primary goal of his treatment will be to:
reduce the viscosity of his blood. Explanation: While hypertension may accompany polycythemia vera, the primary goal of treatment is to control the increase in blood viscosity that accompanies the disease. Polycythemia vera is not associated with increased corpuscular volume and oxygen distribution is not a priority problem.
A 25-year-old female client with primary antiphospholipid syndrome is discussing the possibility of becoming pregnant. The nurse shares which possible complication(s) that can occur as a result of this syndrome? Select all that apply.
spontaneous miscarriage premature birth placental insufficiency Explanation: Primary antiphospholipid syndrome involves autoantibodies that attack protein-binding phospholipids causing an increase in coagulation. Clotting factors are also increased during pregnancy and can contribute to the development of ischemia and thrombosis of the placental blood vessels that interferes with the ability to sustain a healthy pregnancy to term. This syndrome is not associated with the development of gestational diabetes or prolonged labor.
A 42-year-old male client recently diagnosed with liver cancer is noted as at high risk for bleeding abnormalities. The nurse recognizes this risk as a result of:
the reduction of clotting factors synthesized in the liver. Explanation: In liver disease, synthesis of clotting factors is reduced and bleeding may result. Vitamin K would not be produced in large amounts of active form in a diseased liver. Vitamin C deficiency in the diet would not contribute to increased bleeding.
A client is newly diagnosed with impaired platelet function, thrombocytopathia. Which question is most appropriate for the nurse to ask in order to determine the possible cause of this problem?
"Have you been taking aspirin or any nonsteroidal anti-inflammatory drugs (NSAIDs)?" Explanation: The use of aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) is the most common cause of impaired platelet function. Aspirin produces irreversible acetylation of platelet cyclooxygenase activity and consequently the synthesis of TXA2, which is required for platelet aggregation. In contrast to the effects of aspirin, the inhibition of cyclooxygenase by other NSAIDs is reversible and lasts only for the duration of the drug action.
A nurse is reviewing the laboratory data for a hospitalized client. The nurse would notify the health care provider about which results as most concerning?
white blood cell (WBC) count of 2800/µl (2.80 ×109/l) Explanation: Normal range for RBCs is 4.2 to 5.4 ×106/µl (4.2 to 5.4 ×10^12/l) for males and 3.6 to 5.0 × 106/µl (3.6 to 5.0 ×10^12/l) in females, making a result of 4.5 ×10^6/µl (4.5 ×10^12/l) normal. The normal range for platelets is 150,000 to 400,000/µl (150 to 400 ×10^9/l) making 200,000/µl within normal range. The normal range for WBC is 4.8 to 10.8 ×10^3/µl (4.8 to 10.8 ×10^9/l). The client's WBC is below normal. This is referred to as leukopenia. Leukocytes are crucial to our defense against disease. The low WBC count in this client would indicate that the client's immune function may be compromised and the underlying cause of the problem needs to be investigated.
A nurse is caring for a client who has sustained severe trauma and has developed disseminated intravascular coagulation (DIC). The nurse will explain this complication to the family based on which physiologic principle?
Widespread coagulation and bleeding in the vascular compartment Explanation: DIC is a paradox in the hemostatic sequence and is characterized by widespread coagulation and bleeding in the vascular compartment. It begins with massive activation of the coagulation sequence, which leads to fibrin deposition and formation of thrombi in the microcirculation of the body. DIC and its acute manifestations are related to the bleeding problems that occur.
A client has been diagnosed with inherited hypercoagulability. Select the most likely cause.
Factor V gene mutation Explanation: Of the inherited causes of hypercoagulability, mutations in the factor V gene and prothrombin gene are the most common. Among the acquired or secondary factors that lead to increased coagulation and thrombosis are venous stasis due to prolonged bed rest and immobility, myocardial infarction, cancer, hyperestrogenic states, and use of oral contraceptives.
Hemophilia A is a hereditary blood disorder caused by inadequate activity or absence of which blood component?
Factor VIII Explanation: Factor VIII gene deficiency or absence is the cause of hemophilia A. Intrinsic factor and prothrombin are part of the coagulation process and unrelated to hemophilia A. Von Willebrand factor (vWF) disease is caused by a lack of vWF complex, which binds and stabilizes factor VIII.
The nurse is caring for a postsurgical client who is recovering from knee replacement surgery secondary to rheumatoid arthritis. When planning the client's care, the nurse should include what action?
Frequent assessment for signs of thrombosis or hemorrhage. Explanation: This client's history of an inflammatory disease coupled with her recent surgery constitutes a risk for secondary thrombocytosis, which is usually manifested by bleeding or thrombosis. ROM exercises will not directly address this risk. Platelet transfusions and vitamin K injections would exacerbate the problem.
Which substance, when deficient, results in a diagnosis of anemia?
Hemoglobin Explanation: Anemia is a condition of an abnormally low number of circulating red blood cells or hemoglobin level, or both. It is not a disease but a manifestation of a disease process or alteration in body function.
The client is an average-sized adult and has abnormal microcytic hypochromic red blood cells due to a long-term, chronic disease. Which complete blood count (CBC) result is characteristic of this type of anemia?
Hemoglobin 7.8 g/dL (78 g/L) Explanation: Anemia of chronic disease is characterized by a low hemoglobin level, low hematocrit, and low reticulocyte count. The quantity of band cells, immature neutrophils released from the marrow, is unrelated to the anemia.
A nurse is assessing a client who displays pale skin and nail beds. Which laboratory data should the nurse evaluate?
Hemoglobin level Explanation: RBCs contain the oxygen-carrying protein hemoglobin that functions in the transport of oxygen. Pallor of the skin or nail beds is a sign of anemia, which can be indicated by a low Hgb level.
The emergency department nurse is concerned that the client's snake bite may trigger disseminated intravascular coagulation (DIC). If this should occur, which clinical manifestations would be seen?
Hemorrhage Explanation: DIC is hemorrhage in the presence of excessive coagulation. The bleeding may be present as petechiae, purpura, oozing from puncture sites, or severe hemorrhage. Late-stage DIC is characterized by uncontrolled hemorrhaging. Platelet deficit is not present; blood loss causes hypotension and rapid loss of consciousness.
A nurse is monitoring a client with anemia and low oxygen levels. The nurse knows that which condition stimulates the secretion of erythropoietin?
Hypoxia Explanation: Erythropoiesis is governed for the most part by tissue oxygen needs. Any condition that causes a decrease in the amount of oxygen that is transported in the blood produces an increase in red blood cell production. The oxygen content of the blood does not act directly on the bone marrow to stimulate red blood cell production. Instead, the decreased oxygen content is sensed by the peritubular cells in the kidneys, which then produce a hormone called erythropoietin.
Which function is the main job of lymphocytes?
Immune reaction Explanation: Immune reaction is the main job of lymphocytes. Their function in the lymph nodes or spleen is to defend against microorganisms through the immune response.
The pathologic effects of the thalassemias are primarily due to which pathophysiologic process?
Impaired hemoglobin synthesis Explanation: The thalassemias are a heterogeneous group of inherited disorders caused by mutations that decrease the rate of alpha- or beta-globin chains. The pathologic effects of the thalassemias are not direct results of impaired folic acid absorption nor a lack of erythropoietin or iron.
The nurse is caring for a pediatric client who will be having bone marrow aspiration from the posterior iliac crest. The parent asks why the sternum is not used to obtain the sample as this is the site used for another relative. How does the nurse respond?
In children, the sternal bone marrow cavity is much more shallow, increasing risk for damage to underlying organs. Explanation: For bone marrow aspirate, the posterior iliac crest is used in clients older than 12 to 18 months of age as long as there is not a contraindication. Other sites include the anterior iliac crest, sternum, and spinous processes T10 through L4. The sternum is not used in children because the cavity is too shallow, placing the child at risk for mediastinal and cardiac perforation. While other advantages such as having the child facing away from the equipment may exist, this is not the primary reason for site selection, nor are test results.
A client is admitted to the emergency department with a diagnosis of polycythemia. The nurse plans to assess for symptoms related to which problem?
Increased blood viscosity Explanation: Unregulated overproduction of the red cell mass is termed polycythemia, which causes a thickening of the blood and an increased risk of blood clots.
Following a lecture on hemostasis, a nursing student accidently cuts her hand while preparing supper for her family. She watches the laceration very closely. Sure enough, the first thing she notes is:
Initially, it takes a few seconds for blood to appear as a result of vessel spasm. Explanation: There are five stages in hemostasis, with the first step being transient vessel vasospasm. Vessel spasm is initiated by endothelial injury and caused by local and humoral mechanisms. It is a transient event, usually lasting less than 1 minute. For smaller vessels, release of the vasoconstrictor TXA2 is responsible for much of the vessel spasm. Formation of the platelet plug, development of an insoluble fibrin clot, and clot retraction happen after vessel spasm.
The nurse is assessing a client diagnosed with anemia and notes that the client's skin and mucous membranes are pale. The nurse interprets this as:
Insufficient hemoglobin Explanation: The redistribution of the blood from cutaneous tissues or a lack of hemoglobin causes pallor of the skin, mucous membranes, conjunctiva, and nail beds. Tissue hypoxia to the brain causes headache, faintness, and dim vision but is not the direct cause of pallor. Changes in blood viscosity may lead to a systolic murmur.
The rate at which hemoglobin is synthesized depends on availability of which substance?
Iron Explanation: The rate at which hemoglobin is synthesized depends on the availability of iron for heme synthesis.
A client was recently diagnosed with iron deficiency anemia. The nurse anticipates which treatment to be prescribed?
Iron supplementation and dietary teaching Explanation: Decreased ferritin levels usually indicate the need for a prescription of iron supplements such as ferrous sulfate.
A pediatric nurse is treating a 2-day-old infant for jaundice. The treatment involves exposing the infant's skin to fluorescent light at 420-470 nm wavelengths. What does the light do to the bilirubin?
It converts the bilirubin into a soluble form that is easily excreted in the stool and urine. Explanation: Bilirubin in the skin absorbs the light energy and is converted to a structural isomer that is more water soluble and can be excreted. Fluorescent light does not affect vasoconstriction, "bleach" bilirubin, or have any effect on the metabolic rate of the liver.
The nurse is educating a pregnant client about the importance of dietary folic acid to prevent anemia. Which food source will the nurse encourage because it is high in folic acid?
Kale Explanation: Folic acid is readily absorbed from the intestine. It is found in vegetables (particularly the green leafy types), fruits, cereals, and meats. Much of the vitamin, however, is lost in cooking. The most common causes of folic acid deficiency are malnutrition or dietary lack, especially in older adults or in association with alcohol use disorder.
Which type of macrophages are found in the liver?
Kupffer cells Explanation: Macrophages found in the liver are known as Kupffer cells. Histiocytes are macrophages found loose in connective tissue, and microglial cells are brain macrophages. Monocytes are referred to macrophages when they enter the tissues.
A client is experiencing fatigue and laboratory results reveal: Hct 40% (0.40); Hgb 8 g/dL (80 g/L); WBC 8000 (8 x 109/L); and platelets 175,000/ µL (175 ×109/L). The nurse would interpret these results as indicative of which diagnosis?
Low hemoglobin/anemia Explanation: All of the laboratory values are within normal range except for the hemoglobin, which is low. Low hemoglobin is associated with anemia. Anemia is an abnormally low number of circulating red blood cells or level of hemoglobin (or both), resulting in diminished oxygen-carrying capacity.
The practitioner is examining a client and notes that he has small, punctate skin hemorrhages on his abdomen and chest. This finding is suggestive of which lab result?
Low platelets Explanation: Petechiae (small, punctate skin hemorrhages) and ecchymoses often occur on the skin, and bleeding from the nose, gums, vagina or gastrointestinal tract may be seen because of decreased platelet levels.
The student correctly associates macrocytic and enlarged red blood cells with which type of anemia?
Megaloblastic Explanation: Macrocytic and enlarged red blood cells are characteristic of megaloblastic anemia; microcytic and hypochromic of iron deficiency anemia and abnormally shaped red blood cells in sickle cell disease. Normocytic indicates the red blood cells are normal.
During chronic blood loss, iron deficiency anemia occurs. Most clients are asymptomatic until their hemoglobin falls below 8 g/dL (80 g/L). The red blood cells that the body does produce have too little hemoglobin. What is the term for the resulting anemia?
Microcytic hypochromic Explanation: Chronic blood loss does not affect blood volume but instead leads to iron deficiency anemia when iron stores are depleted. It is commonly caused by gastrointestinal bleeding and menstrual disorders. Because of compensatory mechanisms, clients are commonly asymptomatic until the hemoglobin level is less than 8 g/dL (80 g/L). The red cells that are produced have too little hemoglobin, giving rise to microcytic hypochromic anemia. Macrocytic anemia is when the RBCs are larger than normal. Hyperchromic means the cells are a darker color red than they should be.
An adult female, newly diagnosed with possible leukemia, arrives for a bone marrow biopsy. The admission laboratory work includes: red blood cell count (RBC): 3.4 ×106/µL (3.4 ×1012/L); white blood cell count (WBC): 2,500/µL (2.5 ×109/L); platelet count of 80 ×103/µL (80 ×109/L); all below normal values. What assessment is the highest priority for this client?
Monitoring for any type of bleeding. Explanation: When laboratory values show pancytopenia, the client is at increased risk for developing a hemorrhage and this is the priority for this client, especially given the reduced platelet count. Checking for renal function, breath sounds, and cardiac assessment should be performed on all clients, no matter their diagnosis. However, bleeding is a real possibility for this client and should be performed regularly throughout the day.
Which type of cell is the most common leukocyte in normal blood?
Neutrophils Explanation: Granulocytes are a type of white blood cell (WBC) and are divided into 3 types-neutrophils, eosinophils, and basophils. Neutrophils constitute 55% to 65% of the total WBC count, making them the most abundant type of granulocyte. Lymphocytes account for 20% to 30% of the total blood WBC count. Monocytes are the largest in size of the WBCs and constitute approximately 3% to 8% of the total leukocyte count. Platelets are derived from the myeloid stem cells. They contribute to formation of the platelet plug to help control bleeding.
A nurse sends a blood sample to the lab for analysis. Assuming the sample is normal, the nurse anticipates which white blood cells (WBCs) will account for the highest percentage?
Neutrophils Explanation: Neutrophils constitute 55% to 65% of the total WBCs.
A client is admitted to the hospital with an elevated temperature and flank pain. When reviewing the complete blood count (CBC), which level is the most important for the nurse to communicate to the health care provider?
Neutrophils 85% Explanation: Neutrophils are very mobile and are the first cells to go to an area of tissue damage. The elevation in neutrophils indicates that the client has an acute infection (such as pyelonephritis) that is causing the temperature elevation and flank pain.
When a white blood cell with differential count reveals an acute infection, which statement is correct regarding the client's neutrophils?
Neutrophils are the first white blood cell to elevate in an acute infection. Explanation: Neutrophils constitute 55% to 65% of the total numbers of white blood cells and are primarily responsible for maintaining normal host defenses against invading fever producing bacteria and fungi, cell debris, and a variety of foreign substances. Eosinophils are white blood cells that are responsive in an allergic or parasitic infection.
The client with a history of gastrectomy presents with severe anemia, mild jaundice, and spastic ataxia. The lab work demonstrates an elevated mean corpuscular volume (MCV). The practitioner suspects the client has which type of anemia?
Pernicious Explanation: Pernicious anemia is a form of megaloblastic anemia (elevated MCV) caused by atrophic gastritis or gastrectomy, ileal resection, inflammation or neoplasms in the terminal ileum, and malabsorption syndromes that lead to failure to absorb vitamin B12. The loss of red blood cells results in moderate to severe anemia, mild jaundice and, in some cases, eventual spastic ataxia due to demyelination. The other options do not cause these symptoms.
A 75-year-old client with a history of heart valve replacement arrives at the outpatient clinic with multiple red pinpoint lesions. The nurse identifies the lesions as:
Petechiae Explanation: Petechiae are pinpoint red lesions caused by bleeding under the skin and can be noted in the presence of many bleeding disorders, including structural weakening of blood vessels that comes with age.
When a 3-day-old full-term infant has an elevated bilirubin level of 18 mg/dL (307.87 μmol/L), the nurse will expect to support which intervention?
Phototherapy Explanation: Hyperbilirubinemia in the neonate is treated with phototherapy for the best results. Other treatments would include frequent breast-feeding to prevent dehydration, and in severe cases (bilirubin 25-30 mg/dL [427.60-513.12 μmol/L] ), an exchange transfusion would be used. There is no reason to retest without initiating some form of treatment.
A parent has brought her 2-week-old infant to the emergency department due to the infant's persistent and increasing jaundice. Laboratory testing reveals indirect bilirubin level is 28 mg/dL (479 µmol/L), but otherwise a normal physical assessment. Which intervention will most likely be prescribed for this infant?
Phototherapy Explanation: Phototherapy is the standard treatment for mild to moderate hyperbilirubinemia, with exchange transfusion an option for greater risks of kernicterus with more symptomatology. Blood transfusions, phlebotomy, and antibiotics are not indicated in hyperbilirubinemia.
A nurse is reviewing a client's complete blood count (CBC) which indicates thrombocytopenia. Based on this result, which action should the nurse include in the plan of care?
Place the client on bleeding precautions. Explanation: Thrombocytopenia is a decreased number of platelets, which places the client at high risk for bleeding.
A nurse is caring for a client who was recently diagnosed with primary thrombocytosis. The client does not understand why hydroxyurea is given. The best explanation would be that this medication decreases:
Platelet counts Explanation: Hydroxyurea is used in high-risk clients with essential or primary thrombocytosis to decrease the number of platelets by directly affecting the bone marrow.
A client who underwent a bone marrow aspiration has been scheduled for a bone marrow biopsy. The client asks the nurse what the difference is between these two procedures. How should the nurse respond?
"Aspiration obtains a sample of the cells from the marrow, but a biopsy obtains a larger sample to examine structure." Explanation: Bone marrow aspiration is performed with a special needle inserted into the bone marrow cavity, through which a sample of marrow is withdrawn. A biopsy removes an actual sample of bone marrow tissue and allows study of the architecture (structure) of the tissue. Both biopsy and aspirate can be obtained from various sites. The choice of site is based on the client's age, not the type of sample being taken. Usually, the posterior iliac crest is used in all persons older than 12 to 18 months of age. Aspirate examination is not always done prior to bone marrow sampling and the results from bone marrow aspirates are not "often inaccurate."
A client who takes daily sodium warfarin states a desire to start exercising daily. What is the best advice for the nurse to give the client?
"Exercise will be beneficial to you, just be careful not to injury yourself or fall." Explanation: Warfarin acts by decreasing prothrombin and other procoagulant factors. Its main side effect is bleeding. As a client exercises, increased physical activity increases fibrinolytic activity. As sodium warfarin is an anticoagulant, the client who exercises while taking this medication should see increased benefits and less clot formation. The nurse should encourage supervised activity.
A 23-year-old female client has been diagnosed with von Willebrand disease following a long history of "heavy periods" and occasional nosebleeds. Which of the client's statements demonstrates a sound understanding of the new diagnosis?
"I'll make sure to take acetaminophen instead of aspirin when I get aches and pains." Explanation: Most clients with von Willebrand disease, especially less serious variants, require only monitoring and aspirin/salicylates avoidance. It is likely unnecessary for the client to avoid sports. Drugs, clotting factors, and transfusions are likely not required, given the moderate bleeding that the client has experienced to this point.
The mother of a newborn infant questions why her baby needs a vitamin K injection immediately after birth. The best response by the nurse would be:
"Infants are not born with the normal intestinal bacteria that synthesize vitamin K for clotting." Explanation: Vitamin K is needed by newborns to begin the synthesis of blood clotting prior to their establishing the normal intestinal flora. While it may be hospital policy to administer vitamin K, this does not explain to the concerned mother why her newborn is getting an injection.
A client is prescribed low dose (81 mg) aspirin daily. The client refuses the medication stating, "I do not have any pain." The best response by the nurse would be:
"The 81 mg of aspirin daily will help protect you from a stroke or a heart attack." Explanation: The nurse knows the low dose of aspirin (81 mg) is used to prevent platelet aggregation and clot formation in persons who are at risk for myocardial infarction, stroke, or peripheral artery disease. This dose of aspirin will not be therapeutic for preventing pain, so the nurse corrects the client's misconception. Even at 81 mg, aspirin increases the risk for bleeding and will not prevent bleeding. Aspirin is not a thrombolytic, so will not "break apart" a blood clot.
A child with leukemia hears the health care provider tell the parents that the child has "pancytopenia." This child asks the nurse, "What does 'pancy' mean? Am I going to die?" Which response by the nurse is most appropriate for this 10-year-old child?
"This means the chemotherapy has lowered your blood counts including red blood cells, white blood cells and platelets. You are very sick, but we are working hard to make you healthy again." Explanation: Telling a 10-year-old child the truth is usually the best strategy. Most children of this age understand the basic info about blood components so the nurse should explain that the chemotherapy has lowered the blood counts including red blood cells, white bloods cells and platelets. The chemotherapy is not attacking the bone marrow specifically but interferes with production of rapidly dividing cells. The statement about the possibility of death if the child starts bleeding badly might scare a child but definitely can be addressed with and when the child gets critical. The child might be tired with low counts; however, resting alone will not normalize their blood counts.
A nurse is caring for a newborn that has developed a low platelet count. What could be the cause?
Decreased thrombopoietin (TPO) Explanation: TPO stimulates the differentiation of platelets.
The nurse is reviewing the client's laboratory report. Select the report that represents a normal value for leukocytes.
6500 cells/mL (6.5 ×109/L) Explanation: The number of leukocytes, or white blood cells, in the peripheral circulation normally ranges from 4800 to 10,800 cells/mL (4.8 to 10.8 ×109/L).
A client comes to the clinic with a runny nose and scratchy throat. The nurse is evaluating the white blood cell count, which shows an elevated number of white blood cells and an increased percentage of eosinophils. What is the most likely cause of the symptoms?
Allergic reaction Explanation: Eosinophils increase in number during allergic reactions and parasitic infections.
A client in the ICU following a massive myocardial infarction (MI) is receiving both acetylsalicylic acid (ASA) and ticlopidine to prevent further cardiac compromise. The nurse notes a significant decrease in the client's white blood cells and platelets. Which possible cause of these abnormal lab values should the nurse suspect?
Adverse reaction to the ticlopidine Explanation: Serious adverse reactions involving both neutropenia and thrombotic thrombocytopenic purpura (TTP) have been noted with the use of ticlopidine. The neutropenia would manifest as a decrease in neutrophils, which would cause a decrease to the total white blood cell count; the TTP would have a decrease in platelet levels.
To form a platelet plug, platelets are attracted to the damaged vessel. What then occurs within the blood vessel?
Adhesion of the platelets Explanation: There are two processes involved in platelet plug formation, the first of which is platelet adhesion to the vessel subendothelial layer. Fibrinolysis is the process of clot dissolution. Thrombosis is inappropriate formation of clots within the vascular system. Thromboxane A2 (TXA2) is released during platelet aggregation, the step after adhesion.
A client with a diagnosis of hemophilia A has been admitted with bilateral knee pain. The nurse should anticipate performing what intervention during the client's treatment?
Administration of factor VIII and implementation of fall prevention measures Explanation: Clients with hemophilia have a deficit in factor VIII. Administration of vitamin K, platelets, or DDAVP is ineffective because of the absence of this clotting factor. Injury prevention is paramount in the care of a client with a bleeding disorder.
An oncology client is receiving an erythropoietin stimulating agent, epoetin alfa for severe anemia. The client reports severe bone pain (arthralgia). Knowing the basic pathophysiologic principles, how should the nurse explain the bone pain to this client?
Bleeding is stimulating the rapid proliferation of replacement cells by the blood-forming cells in the bone marrow. Explanation: Bleeding stimulates the rapid proliferation of replacement cells by the blood-forming progenitor cells of the bone marrow. This can cause arthralgia (bone pain) as the body is trying to generate more red blood cells within the bone marrow. It is not caused by anoxia or vasoconstriction (i.e., bones do not have blood supply except in the marrow). One side effect of epoetin alfa (or bleeding) is that the bone marrow is being stimulated to produce more red blood cells, which is painful.
The nurse is assessing an 83-year-old adult client for signs and symptoms of anemia. What normal, age-related change increases this client's risk for anemia?
Blood cells are not replaced as quickly as they are in younger clients. Explanation: The red blood cells of older adults are not replaced as promptly as those of their younger counterparts. Existing RBCs remain capable of carrying oxygen, however. Older adults have an increased risk of GI bleeds and aplastic anemia, but these are not considered to be normal, age-related changes.
The client's's primary care physician is reviewing assessment data of a client and suspects a diagnosis of acute leukemia. To confirm the diagnosis, which test would be performed?
Bone marrow analysis Explanation: A definitive diagnosis of acute leukemia is based on blood and bone marrow studies; it requires the demonstration of leukemic cells in the peripheral blood, bone marrow, or extramedullary tissue.
An older adult client arrives with garbled speech, unilateral facial drooping, and weakness and unfortunately dies. Laboratory work reveals hematocrit of 54% (0.54). Which complication of polycythemia could most likely be associated with this client's death?
Cerebral thrombosis Explanation: Unregulated overproduction of the red cell mass is termed polycythemia, which causes a thickening of the blood and an increased risk of blood clots (viscosity).
The nurse's review of a client's laboratory results indicates that inflammation is absent and platelet levels are low. Which test was performed to provide the platelet count?
Complete blood count Explanation: The complete blood count provides the number and characteristics of red blood cells, leukocytes, and platelets. Hematocrit is simply the percentage of RBCs and sedimentation rate indicates inflammation. Bone marrow aspiration is used to examine the stem cells.
Normally, there is a relatively constant number of each type of circulating blood cell. What regulates the number of each type of blood cell?
Cytokines Explanation: Under normal conditions, the numbers and total mass for each type of circulating blood cell remain relatively constant. The blood cells are produced in different numbers according to needs and regulatory factors. This regulation of blood cells is believed to be at least partially controlled by hormone-like growth factors called cytokines. The immune system does not regulate the number of each type of blood cell. The hematopoietic system is the system in which the blood cells are made, but it does not regulate the number of each type of cell. Pluripotent stem cells are the precursors to every type of cell.
A nurse is caring for a client receiving heparin therapy who has developed heparin-induced thrombocytopenia. Which nursing intervention does the nurse anticipate?
Discontinuation of heparin therapy Explanation: In persons with drug-associated thrombocytopenia, there is a rapid fall in the platelet count within 2 to 3 days of resuming a drug or 7 or more days after starting a drug for the first time. The platelet count rises rapidly after the drug is discontinued. The anticoagulant drug heparin has been increasingly implicated in thrombocytopenia and, paradoxically, in thrombosis. The complications typically occur 5 days after the start of therapy and result from heparin-dependent antiplatelet antibodies that cause aggregation of platelets and their removal from the circulation. The antibodies often bind to vessel walls, causing complications such as deep vein thrombosis, pulmonary embolism, myocardial infarction, and stroke. The treatment of heparin-induced thrombocytopenia requires the immediate discontinuation of heparin therapy and the use of alternative anticoagulants to prevent thrombosis recurrence.
A week after starting atorvastatin for high cholesterol, the client returns reporting bleeding from the mouth (mucous membranes) and nose. What priority intervention should the health care provider perform?
Discontinue the atorvastatin immediately. Explanation: In clients with drug-associated thrombocytopenia, there is a rapid fall in the platelet count within 2 to 3 days of resuming a drug or 7 or more days after starting a drug for the first time. The platelet count rises rapidly after the drug is discontinued. Ice can cause vasoconstriction but is hard to apply to the mouth and nose. This client does not have disseminated intravascular coagulation and therefore blood thinners are contraindicated. Stopping the medication should be the best choice. Sending the client to an ENT specialist is not needed at this time.
A client is admitted to the hospital with a diagnosis of deep vein thrombosis and started on intravenous heparin therapy. Seven days later, the client's lab values identify a rapid decrease in platelets. The health care provider recognizes this as:
Drug-induced thrombocytopenia Explanation: Drug-associated thrombocytopenia presents with a rapid fall in the platelet count within 2 to 3 days of resuming a drug or 7 or more days after initiating a drug for the first time. The platelet count rises rapidly after the drug is discontinued. Heparin is one of the drugs that can cause this problem. Immune thrombocytopenic purpura (ITP) is an autoimmune disorder that results in platelet antibody formation and excess destruction of platelets. Thrombotic thrombocytopenic purpura (TTP) and hemolytic-uremic syndrome (HUS) are thrombotic microangiopathies.
The nurse is examining a client's laboratory results. Which result does the nurse use as the best evidence that the client has an active acute bacterial infection?
Elevated number of band cells Explanation: While both the white blood cells (WBCs) and neutrophils will be elevated in a bacterial infection, the number of band cells best identifies that the body is actively responding to this infection. Bands are immature neutrophils, so as the mature neutrophils are depleted while fighting the infection these immature neutrophil band cells appear in greater numbers. Lymphocytes may appear lower on a WBC differential due to the increase in neutrophils consuming a greater portion of the total number of WBCs but it is not a direct measure of response to bacterial infection.
A nurse is evaluating laboratory results of a client diagnosed with a parasitic infection. The tests reveal a large group of cells that are membrane-bound with granules in their cytoplasm that are aiding in the destruction of the parasite. Which cell is the nurse evaluating?
Eosinophil Explanation: People who have helminthic parasites will have an increase in eosinophils in their complete blood count. The specific cytoplasmic granules of the eosinophils stain red with the acidic dye eosin. In parasitic infections, the eosinophils use surface markers to attach themselves to the parasite and then release hydrolytic enzymes that kill it.
Which leukocyte is correctly matched with its function within the body?
Eosinophil—allergic reaction Explanation: Eosinophils, a type of granulocyte, increase in number during allergic reactions. Lymphocytes (agranulocytes) consist of three cell types that are not phagocytes but do have an important role in the immune response. Basophils and mast cells release heparin and histamine in response to allergens. Monocytes and macrophages are phagocytes that engulf antigens.
A nurse is assessing a child brought to the clinic with multiple petechiae and excessive bruising covering his body. Laboratory tests reveal a low platelet count. The nurse is aware that these clinical manifestations are caused due to which pathological process?
Platelets function to form the platelet plug to help control bleeding after injury. Without enough platelets, the blood cannot clot properly and bleeding occurs. Explanation: Thrombocytes, or platelets, are circulating cell fragments of the large megakaryocytes that are derived from the myeloid stem cell. Platelets function to form the platelet plug to help control bleeding after injury to a vessel wall. Their cytoplasmic granules release mediators required for the blood coagulation process. Without enough platelets, the blood cannot clot properly and bleeding occurs. Bleeding and easy bruising may also arise from dysfunctional platelets.
A client presents to the clinic with symptoms of elevated blood pressure, dizziness, red face, pain in fingers and toes, headache, and difficulty concentrating. A blood smear reveals an increased number of erythrocytes. Based on these findings, the nurse anticipates which diagnosis?
Polycythemia vera Explanation: Polycythemia vera is a neoplastic disease of the pluripotent cells of the bone marrow characterized by an absolute increase in total red blood cell mass accompanied by elevated white cell and platelet counts. In polycythemia vera, the clinical manifestations are hypertension, headache, dizziness, inability to concentrate, and some difficulty with hearing and vision because of decreased cerebral blood flow. Venous stasis gives rise to a plethoric appearance or dusky redness, even cyanosis, particularly of the lips, fingernails, and mucous membranes. Because of the increased concentration of blood cells, the person may experience itching and pain in the fingers or toes, and the hypermetabolism may induce night sweats and weight loss.
The client explains to her new provider that she receives periodic phlebotomies to decrease her red blood cell mass. The provider believes the client may have:
Polycythemia vera Explanation: Primary polycythemia, or polycythemia vera, is characterized by an absolute increase in total red blood cell mass. The goal of treatment is to reduce blood viscosity. Withdrawing blood by periodic phlebotomy to reduce red blood cell volume can do this. Sickle cell and beta-thalassemias are treated with transfusions. Megaloblastic anemias, caused by vitamin B12 and folic acid deficiencies, are treated by replacement of these nutrients.
Which anatomical site would the nurse expect to monitor when caring for an adult client who has just had a bone marrow aspiration performed?
Posterior iliac crest
The nurse is preparing a client with suspected leukemia for a bone marrow and biopsy. What preferred site will the nurse be sure is accessible for the physician?
Posterior iliac crest Explanation: Usually, the posterior iliac crest is used in all people older than 12 to 18 months of age. Other sites include the anterior iliac crest, sternum, and spinous processes T10 through L4. The sternum is not commonly used in children because the cavity is too shallow and there is danger of mediastinal and cardiac perforation.
A young man has been diagnosed with hemophilia, and the nurse is planning his discharge teaching. The nurse knows to include what in the discharge teaching?
Prevent trauma to the body. Explanation: Hemophilia A is an X-linked recessive disorder that primarily affects males. Approximately 90% of persons with hemophilia produce insufficient quantities of the factor VIII. The prevention of trauma is important in persons with hemophilia.
Knowing that thrombotic thrombocytopenic purpura (TTP) results in thrombi in the microcirculation system, the health care worker should assess the client for which manifestations? Select all that apply.
Red/purple skin discoloration that does not blanch when pressure is applied (purpura) Petechiae over the entire body Confusion caused by neurologic abnormalities Explanation: The clinical manifestations of TTP include purpura, petechiae, vaginal bleeding, and neurologic symptoms ranging from headache to seizures and altered consciousness.
Removal of a client's peripheral intravenous catheter resulted in brief bleeding and the loss of a small amount of blood. Which process occurred during the formation of the platelet plug that helped to stop blood flow?
Release of von Willebrand factor from the endothelium Explanation: The release of von Willebrand factor from the epithelium contributes to platelet adhesion and the eventual formation of a platelet plug. Activation of factor X and the conversions of prothrombin to thrombin and fibrinogen to fibrin threads take place during the stage of blood coagulation.
When red blood cells age, which organ is responsible for their destruction?
Spleen Explanation: When red blood cells age, they are destroyed in the spleen.
A nurse assessing a client with an acute exacerbation of polycythemia vera notes coolness to the right leg and foot, pale color, and an absent right pedal pulse. Based on these findings the nurse suspects that the client has developed which complication?
Thrombosis in the right leg Explanation: Unregulated overproduction of the red cell mass is termed polycythemia. Thrombocytosis occurs when the bone marrow produces too many platelets and elevated viscosity contributes to a prothrombotic state, placing the client at risk for vascular occlusion. If arterial occlusion occurs, the decrease in supply of oxygenated blood distal to the clot presents as pallor, coolness, and absent pulses. Compartment syndrome can also impede arterial blood flow, but is associated with localized trauma, not polycythemia. Infection leads to redness and warmth and will not affect the peripheral pulse. Edema does not lead to signs of acutely diminished peripheral blood flow.
A client diagnosed with autosomal dominant von Willebrand factor disease (vWF) is experiencing mild to moderate bleeding. The health care provider would classify the diagnosis as:
Type 2 Explanation: Type 2 vWF is an autosomal dominant disorder that is characterized by defects in vWF and results in mild to moderate bleeding. Types 1 and 3 are associated with reduced levels of vWF. There is no type 4.
Stem cell transplantation has been shown to provide potential cures for diseases such as aplastic anemia and the leukemias. What are the sources of stem cells used for transplant?
Umbilical cord blood and bone marrow Explanation: Sources of the stem cells include bone marrow and umbilical cord blood. All replenish the recipient with a normal population of pluripotent stem cells. Immature embryonic cells do not necessarily contain stem cells. Immature neural cells are not stem cells. Yellow bone marrow does not make blood cells, so it would not contain stem cells.
To form a platelet plug, platelets must adhere to the vessel inner layer. For this to occur, which protein molecule is required?
Von Willebrand factor Explanation: Platelet adhesion requires a protein molecule called von Willebrand factor (vWF). This factor is produced by both megakaryocytes and endothelial cells and circulates in the blood as a carrier protein for coagulation factor VIII. The plasma also contains a plasma protein called plasminogen, which gets activated and converted to plasmin, an enzyme capable of digesting the fibrin strands of the clot. The extrinsic pathway of coagulation, which is a much faster process, begins with trauma to the blood vessel or surrounding tissues and with the release of an adhesive lipoprotein called tissue factor (also known as thromboplastin or factor III) from the subendothelial cells. Thromboxane A2 (TXA2) is released during platelet aggregation, the step after adhesion.
A 10-month-old infant has begun to take his first steps and his mother has brought him for assessment because of swelling in his ankles and knees. The mother also states that he was eager to walk but has now regressed and cries when she tries to encourage it. The clinician should:
assess the child for signs and symptoms of hemophilia A. Explanation: The child's presentation is characteristic of hemophilia A, not DIC or von Willebrand disease. Vitamin K does not affect the physiology of hemophilia.
A nurse on an oncology floor is treating a client who is anemic following chemotherapy. The drugs being administered are designed to increase the number of red blood cells in circulation. These drugs are likely agonists of:
cytokines. Explanation: RBC production is directed by cytokines and growth factors. Lymphokines are used for communication between lymphocytes, and trophic and secondary hormones are too broad an answer to this question.
