Hematological system
Decreased vitamin B12 level
(<150 pg/mL)
Hgb
- 14to 18 males - 12 to 16 females
Hct
- 40 to 54% males - 37 to 47% females
acute mylogenous leukemia (AML)
- 80% of acute leukemia in adults
lead poisoning
- > 5 dl - leads to iron deficiency anemia - Burtonian lines- blue line at gum line - > 45 needs chelation therapy
normocytic normochromic anemia
- ACD - acute blood loss - early IDA
Reticulocyte count
- Assessment of bone marrow function - 1-2 % normal
pernicious anemia management/tx
- B12 (cyanocobalamin 100 IM x 1 week - maintenance requires lifelong monthly admins
Leukemia lab/Dx
- CBC w/ subnormal RBC/Neutrophils - Elevated ESR - chemo - bone marrow transplant/aspiration
Lymphoma lab/Dx
- CT, XR, u/s, MRI - biopsy
sickle cell anemia
- Chronic hemolytic anemia - acute exacerbation causes vessel obstruction - pain from tissue ischemia/blood hyperviscosity - African American - dehydration/Stress
Anemia of chronic disease
- Chronic normocytic, normochromic anemia - assoc w/ chronic inflammation, infection, renal failure, and malignancy
Thalassemia lab/Dx
- Decreased Hgb - Low MCV (microcytic) - Lov MCHC (hypochromic) - normal TIBC - Normal Ferritin - Decreased Ä and B Hgb chains
Hemophilia
- Deficiency of factor VIII
Lymphoma
- Diagnosed by biopsy of enlarged lymphnodes
IDA treatment
- Elemental iron until H&H normalizes - replace iron stores take up to 4 months
dx test for iron deficiency anemia
- Ferritin (decreased, N 20-400) - TIBC (elevated 250-410)
Folic acid deficiency anemia management/Tx 3.1 to 17.5
- Folate 1 mg PO daily - Foods high in folic acid (bananas, peanut butter, fish, green leafy vegetables, iron fortified breads/cereal)
sickle cell anemia
- Give Pneumovax 23
Folic acid deficiency anemia lab/Dx
- Hct and RBC decreased - MCV elevated (macrocytic) - MCHC normal (normochromic) - serum folate decreased - red blood cell folate < 100
sickle cell anemia lab/Dx
- Hgb decreased
pernicious anemia lab/dx
- Hgb, Hct and RBCs decreased - MCV increased microcytic - Serum B12 decreased (< 0.1)
RDW (red cell distribution width)
- IDA increased - Thalassemia normal or slightly increased - ACD normal
iron deficiency anemia cause
- Iron loss exceeds intake so storage is depleted - blood loss, impaired absorption
Koilonychia is associated with
- Iron-deficiency anemia - spoon-shaped nails. The finger nails are thin and have a concave shape
iron deficiency anemia labs/Dx
- Low H&H - Low MCV (microcytic) - Low MCHC (hypochromic) - Low serum iron - Low serum ferritin - High TIBC - High RDW
Folic acid deficiency anemia
- Macrocytic, normochromic anemia - d/t folic acid deficiency - glossitis (strawberry tongue, apthous ulcer
MCV (mean corpuscular volume)
- Microcytic 80 fl - normocytic 80-100 fl - macrocytic 100 fl
Folic acid deficiency anemia vs B12
- No neurological signs are seen
Polycythemia management
- Phlebotomy, remove blood - aspirin therapy - refer
iron deficiency anemia s/s
- Pica (clay and ice) - dyspnea/fatigue - palpitation/weakness - tachycardia - postural hypotension
Multiple myeloma is a malignancy of
- Plasma cells - Adult >60 y/o - A cancer of the plasma cells. Symptoms of fatigue, weakness, and bone pain that is usually located in the back or chest. Causes proteinuria with Bence-Jones proteins, hypercalcemia, normocytic anemia. More common in older adults.
Leukemia
- Thrombocytopenia - Bone marrow aspiration and biopsy - Petechia and hematomas - Acute lymphocytic leukemia (most common cancer in Peds)
sickle cell anemia s/s
- delayed growth and development - increased susceptibility to infections - sudden onset severe pain in extremities, back, chest, and abd - aching joint pain - weakness - dyspnea
RDW (red cell distribution width)
- differentiates between IDA, thalassemia, anemia of chronic disease
Infants w/ iron deficiency anemia
- early intake of cow's milk before 9 months
IDA S/S
- fatigue - Pica - spoon shaped nails - H&H low - LOW MCV - LOW MCHS - LOW RBCs - RDW increased - TIBC increased - Serrum Ferritin < 30 - Serum iron low - Retic count low
Hemochomatosis s/s
- fatigue - joint pain - pain in knuckles of pointer and middle finger
Leukemia S/S
- fatigue - weakness - anorexia - generalized lymphadenopathy - wt loss
Polycythemia s/s
- fatigue - weakness - visual disturbance - HA
sickle cell anemia management/tx
- fluids for dehydration - analgesics for pain - oxygen for hypoxia
factors that precipitate sickle cell anemia
- hypoxia - high altitudes - dehydration - physical /emotional stress - surgery - blood loss
Hemochomatosis management
- iron chelation - No iron rich foods
microcytic hypochromic anemia
- iron deficiency anemia - thalassemia anemia - lead poisoning
Non-Hodgkin's Lymphoma
- lymphadenopathy - most common 20-40 years
pernicious anemia B12 N > 250
- macrocytic, normochromic - malabsorption of B12
Hodgkin's lymphoma
- more common in 32 years - cervical adenopathy - reed sternberg cells differentiate from non-hodgkins
Acute Lymphocytic Leukemia (ALL)
- more difficult to cure in adults than children - pancytopenia w/ circulating blasts
MCHC (mean corpuscular hemoglobin concentration)
- normochromic 32-36% - hypochromic < 32% - Hyperchromic >36 %
iron deficiency anemia treatment
- oran ferrous sulfate 300-325 1-2 hrs after meals - do not take with antacid - Vit C helps w/ absorption - Foods high in iron (raisins, green leafy vegetables red meats, citrus products, iron fortified bread/cereal
Anemia of chronic disease s/s
-Hgb/Hct low - MCV (normocytic) - MCHC (normochromic) - Serum iron and TIBC low - Serum ferritin is high >100
A patient has labs drawn for a routine follow-up. The labs reveal a normal complete blood count. Which is considered a normal hemoglobin/hematocrit ratio?
1:3 In a healthy patient, a normal hemoglobin to hematocrit ratio is 1:3.
Normochromic
32% to 36 %
MCHC (mean corpuscular hemoglobin concentration)
32-36 g/dL
Serum Iron
50-150
MCV (mean corpuscular volume)*
80-100
MCV normocytic
80-100 (anemia of chronic disease, sickle cell anemia)
hypochromic
< 32%
MCV in microcytic anemia
< 80 (Iron deficiency/ thalassemia anemia)
MCV macrocytic Megaloblastic anemia
> 100 (B12, folate deficiency, alcoholism)
Hyperchromic
> 36
Hodgkin's Lymphoma
A cancer of the beta lymphocytes (B cells). Night sweats, fevers, and pain with ingestion of alcoholic drinks. Generalized pruritus with painless enlarged lymph nodes (neck). Anorexia and weight loss. Higher incidence among young adults (20-40 years) or older adults (>60 years), males, and Whites. Identified by the presence of Reed-Sternberg cells.
Non-Hodgkin's Lymphoma*
A cancer of the lymphocytes (usually B cells) and killer cells. Usually occurs in the older adult (>65 years) and presents with night sweats, fever, weight loss, generalized lymphadenopathy (painless). The prognosis is poor.
Hemochomatosis
A condition of abnormally high iron levels which may cause liver damage, diabetes mellitus, and skin pigmentation
Polycythemia
A disorder characterized by an abnormal increase in the number RBCs and hematocrit
Thalassemia Minor
A genetic disorder in which the bone marrow produces abnormal hemoglobin (defective alpha- or beta-globin chains). Normal hemoglobin contains two alpha and two beta chains. Results in a microcytic/hypochromic anemia. Ethnic groups: Occurs in people from the Mediterranean, North Africa, Middle East, and Southeast Asia. Alpha thalassemia is more common in Southeast Asians (Chinese, Cambodians, Filipinos, Thai people).
A parent brings her teenager into the clinic. Upon questioning, the parent states that the family recently migrated from Asia and is unsure of vaccination status. Labs were drawn with the following results: alanine aminotransferase (ALT), 140 International Units/mL; aspartate aminotransferase (AST), 130 International Units/mL; positive anti-hepatitis A virus (HAV) IgG; and positive anti-HAV IgM. Which diagnosis is most consistent with these lab findings?
Acute hepatitis A infection Active infection of hepatitis A includes the presence of positive anti-HAV IgM antibodies irrespective of the presence of anti-HAV IgG.
An adult patient was recently diagnosed with leukemia. Which type has the lowest survival rate over 5 years?
Acute monocytic leukemia Acute monocytic leukemia has a 28.3% five-year survival rate for both genders.
A toddler-aged patient was diagnosed with iron deficiency anemia 6 weeks ago and started on oral iron supplementation at 3 mg/kg/day. The parents and patient have returned for a 3-month follow-up visit to determine if the iron supplements have been effective. The nurse practitioner is most concerned about which repeat lab result?
An increase in mean corpuscular volume A decrease in hemoglobin level**** An increase in serum ferritin level A decrease in red cell distribution width (RDW) The hemoglobin should increase with iron supplementation. If it decreases despite supplementation, further investigation is warranted.
Pernicious anemia: Initially, give
B12 injections 1,000 mcg (1 mg) per week for 4 weeks; then monthly B12 injections for lifetime. Alternative is very high oral doses of B12 (1,000-2,000 mcg) PO daily. Parenteral replacement should be used for patients with neurologic changes and/or concerns regarding gastric absorption of vitamin B12.
A school-aged child presents to the clinic with a petechial rash. The patient had an episode of chickenpox two weeks ago. Which test does the nurse practitioner order?
CBC A CBC with a platelet count of fewer than 100,000 is found in acute thrombocytopenic purpura.
A 54-year-old female patient presents to the clinic for a routine wellness exam. The patient is a non-smoker and has a negative family history for cancer. Screening for which three cancers should be discussed with this patient?
Colorectal cancer Regular screening for colorectal cancer is recommended beginning at ages 45-50. Fecal occult blood testing, sigmoidoscopy, and colonoscopy are the screening methods used. Screening should continue until age 75 years. Cervical cancer Women between the ages of 30 and 65 should have a Pap test (and a human papillomavirus test) every 5 years, or a Pap test alone every 3 years. Women with a history of serious cervical pre-cancer cytology should be tested for 20 years following the diagnosis, regardless of age. Breast cancer Women ages 45-54 should have yearly screening mammograms. Women 55 years or older may continue to have yearly screening or switch to mammograms every 2 years, depending on personal health history.
An adult patient presents with concern for a possible allergic reaction. While at a party that served heavy appetizers, the patient developed flushing, pruritus, and tingling of the tongue and lips. The patient has no history of similar reactions in the past, is not on any medications, and was drinking only water. Which is the most common food allergy in adults?
Crustaceans Crustaceans are shellfish (shrimp, crab, lobster). They are the most common food allergy in adults. Seafood allergies can develop in children but are less common.
A patient presents for follow-up on recent blood work with symptoms of fatigue and numbness and tingling in the hands and feet. Current medications include atorvastatin, lisinopril, hydrochlorothiazide, omeprazole, and warfarin. Labs are as follows: RBC 3.8 10^12/L, Hgb 11.1g/dL, hematocrit (Hct) 33 %, MCV 125 fL. Supplementation of which vitamin will most likely be recommended after additional testing?
Cyanocobalamin The lab values are consistent with megaloblastic anemia with an MCV greater than 120 fL. Symptoms of fatigue and numbness and tingling in the hands and feet are consistent with B12 deficiency. Long-term use of proton pump inhibitors such as omeprazole (Prilosec) can reduce the absorption of vitamin B12 (cyanocobalamin); therefore, the nurse practitioner should evaluate for serum vitamin B12 deficiency. Serum vitamin B12 levels less than 400 pg/mL meet diagnostic criteria for deficiency.
A developmentally normal toddler-aged patient presents to the clinic with a pruritic urticarial rash, sneezing, and hoarseness following a meal an hour ago. The patient has no medical history and is not on any medications. Which food allergies are children most likely to outgrow as they age?
Egg Egg allergy impacts between 1% and 9% of young children but typically resolves as they grow older. It is not a common allergy in adults. Egg allergy is a common allergy in children and is linked to the subsequent development of environmental allergies and asthma. Egg allergies typically resolve over time, with 71% resolved by age 6 years.
Folic Acid-Deficiency Anemia/ classic case
Elderly patient and/or alcoholic older man complains of anemia signs/symptoms (tiredness, fatigue, pallor, and a reddened and sore tongue, or glossitis). No neurological complaints. If anemia is severe (applies to all anemias), may have tachycardia, palpitations, angina, or HF.
Iron-Deficiency Anemia Versus Thalassemia Trait
Ferritin Level Low in iron deficiency Normal to high in thalassemia
Iron-Deficiency Anemia/Tx
Ferrous sulfate 325 mg PO TID between meals (take with vitamin C or orange juice for better absorption). Treat iron-deficiency anemia from 3 to 6 months to restore ferritin stores. Use of cast-iron cookware also provides additional iron. Common side effects of iron: Constipation, black-colored stools, stomach upset may occur. Check the reticulocyte count and CBC approximately 2 weeks after starting supplementation to check for treatment response (elevated reticulocytes, hemoglobin/hematocrit will increase).
The majority of serum alpha fetoprotein is produced by the:
Fetal liver
A young adult Asian patient presents to the clinic with symptoms of fatigue. CBC demonstrates a mean corpuscular volume of 110 fL and decreased hemoglobin. Which four choices are possible causes of the patient's macrocytic anemia?
Folate deficiency Alcoholism B12 deficiency Hypothryoidism Folate deficiency can result in a megaloblastic, macrocytic anemia. Alcoholism can cause a nonmegaloblastic, macrocytic anemia. Vitamin B12 deficiency is a common cause of megaloblastic, macrocytic anemia. Hypothyroidism can be a cause of nonmegaloblastic, macrocytic anemia.
A young adult patient informs the nurse practitioner that they are starting a vegan diet. Which supplement is recommended?
Folic acid Iron Branched-chain amino acids Vitamin B12**** Vitamin B12 is obtained from animal products and should be supplemented on a vegan diet. A vegan diet excludes all animal products such as dairy, eggs, and meat. Vitamin B12 is primarily found in foods of animal origin and should be supplemented on a vegan diet.
Alcoholics will have what type of anemia?
Folic acid deficiency anemia
macrocytic normochromic anemia
Folic acid or Vitamin B12 deficiency
The nurse practitioner prescribes an adult patient with iron deficiency anemia an iron supplement. Which may enhance dietary iron absorption?
Foods high in vitamin C
An older adult patient takes 81 mg aspirin once daily and is noted to have microcytic anemia. Which is the most likely cause of the patient's anemia?
GI bleeding Since this patient is taking aspirin, the patient is at a higher risk of having a GI bleed, which can cause anemia and iron deficiency.
Vitamin B12 Deficiency
Gradual onset of symmetrical peripheral neuropathy starting in the feet and/or arms. Other neurological signs are numbness, ataxia (positive Romberg test), loss of vibration and position sense, impaired memory, and dementia (severe cases). Peripheral smear shows macro-ovalocytes, some megaloblasts, and multisegmented neutrophils (more than five to six lobes).
Polycythemia Labs/Dx
Hemoglobin > 18.5/16.5
What is the best diagnostic test for thalassemia?
Hemoglobin electrophoresis
Which of the following tests would you recommend to patients to confirm the diagnosis of beta thalassemia or sickle cell anemia?
Hemoglobin electrophoresis
Dx test for Sickle cell anemia
Hemoglobin electrophoresis (goldstandard)
Dx test for Thalassemia Minor
Hemoglobin electrophoresis (goldstandard)
A male infant presents to the clinic for a well-exam. The infant has a paternal uncle with hemophilia A. Which information should be given to the parents during the visit?
Hemophilia A is an X-linked recessive disorder that cannot be passed from father to son. Hemophilia A icannot be passed from father to son.
Accompanied by a parent, a school-aged patient presents to the clinic with symptoms of craving and chewing ice. Which three lab results confirm a diagnosis of iron deficiency anemia?
High ferritin level Low serum iron**** Low unsaturated iron-binding capacity High total iron-binding capacity**** A low transferrin saturation****
During a routine annual physical, an adult patient reports taking multiple over-the-counter vitamins and nutritional supplements. Which two supplements should the nurse practitioner advise against without a documented deficiency?
Iron Vitamin E Vit C is ok B12 is ok zinc is ok
A young adult patient who migrated from Southeast Asia presents to the clinic for follow-up after routine labs were completed. Which disorder is most consistent with a normal red blood cell distribution width (RDW) and low mean corpuscular volume (MCV)?
Iron deficiency Thalassemia**** Folate deficiency Vitamin B12 deficiency Thalassemia is a type of inherited blood disorder in which the RDW is normal and the MCV is low. Additionally, the red blood cell count is normal to increased and the mean corpuscular hemoglobin is low.
A school-aged patient with a history of anemia presents for an iron absorption test. The iron rises by 150 ug/dL after administration of 1 mg/kg of iron. Which is the most likely diagnosis?
Iron deficiency anemia Most iron deficiency anemias in children are a result of nutritional deficiencies. A ferritin value of less than 12 ng/mL is highly suggestive of iron deficiency anemia. Oral ferrous sulfate is a standard treatment. Most iron is absorbed in the small intestine, and the fact that this child's level rose significantly after ingestion is an indicator of iron deficiency anemia related to nutritional deficiency.
Koilonychia is associated with which of the following conditions?
Lead poisoning Beta thalassemia trait B12 deficiency anemia Iron-deficiency anemia****
The sentinel nodes (Virchow's nodes) are found at the:
Left supraclavicular area The sentinel nodes are found at the supraclavicular area of the chest. They are the first lymph nodes that a cancer lesion will drain into. Therefore, when cancer is diagnosed, these nodes are biopsied to see whether the cancer has spread into the lymph system.
An adult patient presents to the nurse practitioner with fatigue, ice craving, and restless leg syndrome. Which lab finding would raise concern for the early development of iron deficiency anemia?
Low ferritin Decreased ferritin is seen prior to a decline in Hgb and should raise concern for the pending develpment of iron deficiency anemia. Restless leg syndrome and ice craving are often seen with iron deficiency.
A young adult female patient presents to the clinic with reports of heavy menses and fatigue. The nurse practitioner diagnoses her with iron deficiency anemia. Which CBC finding is consistent with iron deficiency anemia?
Low mean corpuscular volume A low MCV is found in iron deficiency anemia.
An older adult patient presents with worsening dyspnea for the past 4 weeks. The patient reports fatigue, a 4.5‑kg (10‑lb) weight loss, and night sweats. On examination, the nurse practitioner notes the patient has mild respiratory distress with a respiratory rate of 22 breaths/min. and blood pressure of 134/76 mm Hg. Mild generalized lymphadenopathy, with the largest node measuring 1.5 cm, is also noted on examination. Which diagnosis is the priority on the list of differentials?
Lymphoma Patients typically report a sudden growth in a neck, chest, or abdominal lymph node that is accompanied with night sweats.
Order both vitamin B12 and folate levels when evaluating
MCV greater than 100 fL (even if no neurological symptoms).
The red blood cells in pernicious anemia will show:
Macrocytic and normochromic cells
folate-deficiency anemia?
Macrocytic and normochromic red blood cells
An older adult patient presents to the clinic with fatigue, glossitis, anorexia, and paresthesias. Laboratory results show macrocytic normochromic anemia. Which finding may help distinguish folic acid deficiency from pernicious anemia?
Macrocytic anemia Glossitis Normochromic anemia Paresthesias**** Paresthesias are more likely to be present in pernicious anemia because of a vitamin B12 deficiency.
A middle-aged adult male patient presents to the clinic with symptoms of fatigue and malaise. Which three CBC findings are consistent with a suspected diagnosis of iron deficiency anemia?
Mean corpuscular hemoglobin (MCH) of 22.6 pg Red blood cell distribution width of 18.4% Mean corpuscular volume (MCV) 69.7 fL
A middle-aged adult patient presents to the clinic for follow-up after routine labs were completed. The patient's hemoglobin is 10.5 g/dL. Which red cell indices give the nurse practitioner information regarding the size of the patient's red blood cells?
Mean corpuscular volume (MCV) Mean corpuscular volume measures the average size of red blood cells.
Which of the following findings is seen in a patient with folate-deficiency anemia?
Microcytic and hypochromic red blood cells Microcytic and normochromic red blood cells Normal size and color of the red blood cells Macrocytic and normochromic red blood cells****
Beta thalassemia minor is considered a:
Microcytic anemia Beta thalassemia minor is a genetic disorder in which the bone marrow produces small, pale, red blood cells in which mild hypochromic, microcytic anemia occurs.
Lead poisoning can cause which type of anemia?
Mild macrocytic anemia Normocytic anemia Microcytic anemia**** Mild hemolytic anemia
Iron-Deficiency Anemia/Etiology
Most common cause is blood loss (overt or occult). Reproductive-aged females (heavy periods, pregnancy), poor diet, GI blood loss, postgastrectomy, and increased physiologic requirement are risk factors. Infants: Rule out chronic intake of cow's milk before 12 months of age (causes GI bleeding) in anemic infants.
Chronic Lymphocytic Leukemia (CLL)
Most common leukemia in adults Lymphocytosis (hallmark of disease) 42,000 WBC Median survival is 10 years
Thalassemia treatment
No treatment in moderate disease RBC transfusion Splenectomy No iron, can cause iron overload
When classifying malignant tumors, which three parameters are mandatory?
Nodes Nodes (N) refers to the number of nearby nodes that have cancer cells. Metastasis (M) Metastasis (M) refers to whether or not the cancer has spread to surrounding areas. Tumor The tumor (T) refers to the size and extent of the main tumor.
TIBC (total iron binding capacity)
Normal 250-450
Chronic Myelogenous Leukemia (CML)
Occurs in older than 40 Philadelphia chromosome seen in leukemic cells (hallmark of disease)
Pernicious Anemia/ classic case
Older to elderly woman complains of gradual onset of paresthesias on her feet and/or hands that is slowly getting more severe. She has pallor, pale conjunctiva, glossitis, and other signs of anemia. Neuropathic symptoms may include any of the following: Tingling/numbness of hands and feet Neuropathy starts in peripheral nerves and migrates centrally Difficulty walking (gross motor) Difficulty in performing fine motor skills (hands) Motor tests: Weak handgrip, decreased vibration sense, abnormal Romberg, and so forth. Inflamed tongue or glossitis (not a specific finding because it is found in other disorders) are seen.
An anxious young adult patient presents to urgent care reporting pruritic urticarial rash, tingling of the lips and tongue, throat tightness, and now tightness in the chest with wheezing. The patient reports a history of allergy to shrimp and may have accidentally eaten shellfish at a nearby cafe 30 minutes prior to arrival. Which three interventions should be initiated?
Oxygen Diphenhydramine Epinephrine Epinephrine is the first and most important treatment. Doses at 0.3-0.5 mg should be given IM in the mid-outer thigh. Most patients will improve with the first dose, but doses can be repeated after 5-15 minutes if needed. There is no contraindication to epinephrine in the setting of anaphylaxis.
Iron-Deficiency Anemia/Classic Case
Pallor of the skin, conjunctiva, and nail beds. Complaints of daily fatigue and exertional dyspnea. May have glossitis (sore and shiny red tongue) and angular cheilitis (irritated skin or fissures at the corners of the mouth). Cravings for nonfood items such as ice or dirt (pica). Severe anemia will cause spoon-shaped nails (koilonychia), systolic murmurs, tachycardia, or heart failure.
The nurse practitioner is reviewing the labs of a middle-aged patient who had gastric bypass surgery approximately two years prior. The patient's hemoglobin, hematocrit, and vitamin B12 level are all low, with a modest increase in the indirect bilirubin level and mean corpuscular volume (MCV). Which type of anemia is most likely?
Pernicious anemia With pernicious anemia (vitamin B12 deficiency), the mean corpuscular volume (MCV) is commonly markedly elevated, vitamin B12 levels are low, and the indirect bilirubin is elevated. Pernicious anemia is the most common anemia following gastric bypass surgery because the digestive tract has been altered, which may interfere with the absorption of nutrients.
Multiple myeloma is a malignancy of the:
Plasma cells
A patient presents to the clinic with pernicious anemia. Which three are expected examination findings?
Positive Babinski**** A positive Babinski sign is abnormal in adults and may be a manifestation of pernicious anemia. Hearing loss Hearing loss is more likely to be associated with iron deficiency anemia. Glossitis**** Vitamin B12 deficiency may cause tongue swelling, pain, and papillae reduction. Myerson sign The Myerson sign is a blinking reflex test that may indicate early neurologic disease; it is not typically present in vitamin B12 deficiency. Positive Romberg**** A positive Romberg test is an abnormal finding and may be a result of a vitamin B12 deficiency.
An adult patient was recently diagnosed with lymphoma. Which finding differentiates Hodgkin lymphoma from non-Hodgkin lymphoma?
Reed-Sternberg cells Reed-Sternberg cells are present in Hodgkin's disease.
An adult female patient presents to the clinic reporting a painful irritated area on her right breast. Upon exam, the patient's temperature is 101.2 °F (38.4 °C) she has a 5 × 5-cm fluctuant, erythematous, and tender mass located in the upper outer quadrant of her right breast. The patient is currently in remission from breast cancer. Which is the best next step?
Refer the patient for a same-day appointment with a breast surgeon. A complex febrile patient who may require surgical intervention is beyond the family nurse practitioner's scope of practice and requires an appropriate referral. In this situation, a breast surgeon or specialist would be best, and considering the patient's acute presentation, the referral should be scheduled for the same day. The patient is febrile with an infected abscess and should be treated right away, not at home with antibiotics or later with a different healthcare provider. The nurse practitioner should not excise and drain the abscess in the clinic.
All of the following conditions are associated with an increased risk of normocytic anemia except:
Rheumatoid arthritis Systemic lupus erythematosus Polymyalgia rheumatica Pregnancy****
Iron-Deficiency Anemia Versus Thalassemia Trait*
Serum Iron Decreased in iron deficiency Normal to high in thalassemia
Which of the following laboratory tests would you order for an older diabetic man with the following complete blood count (CBC) results: hemoglobin = 11 g/dL, hematocrit = 38%, mean corpuscular volume (MCV) = 105 fL, and normal reticulocyte count?
Serum ferritin and a peripheral smear Hemoglobin electrophoresis Serum folate acid and B12 level**** Schilling test
A middle-aged patient presents to the clinic with symptoms of fatigue. The patient takes a daily multivitamin with iron for iron deficiency anemia. Which three lab tests could be affected by taking an iron supplement within 24 hours of testing?
Serum iron Total iron binding capacity (TIBC) Transferrin
An African-American infant patient is brought to the clinic by parents who report that the patient is often inconsolable, does not sleep well, and is fussy with an arched back. Upon exam, there are ulcers on the extremities, and the patient is tachypneic. Which is the most likely diagnosis?
Sickle cell anemia Sickle cell crises often result in pain, shortness of breath, and ulcers.
An adult presents with symptoms of an acute allergic reaction. Which three symptoms raise concern for anaphylaxis?
Tachycardia Wheezing Flushing
A toddler-aged patient presents to the clinic with iron deficiency anemia. The nurse practitioner prescibes oral liquid iron. Which instructions should be given to the patient's parents to maximize iron absorption?
Take iron on an empty stomach The best iron absorption occurs on an empty stomach. Iron should be given one hour before meals or two hours following a meal and taken with water or juice.
A young adult female patient presents to the clinic for treatment of mild iron deficiency anemia. Which four recommendations does the nurse practitioner provide for iron supplementation?
Take iron twice daily NO Eat foods rich in iron**** Avoid taking iron with dairy products**** Take iron with ascorbic acid**** Take iron with a stool softener**** Twice daily dosing of iron has not been shown to improve iron absorption. Eating foods rich in iron is a key recommendation in treating iron-deficiency anemia. Dairy products can inhibit iron absorption. Ascorbic acid increases the absorption of iron. Stool softeners can prevent constipation caused by the use of oral iron supplementation.
Which of the following is a true statement about the effect of aspirin on platelet function?
The effect on platelets is reversible The effect on platelets is reversible and lasts only 1 week The effect on platelet function is minimal The effect on platelet function is irreversible and lasts 7-10 days****
During the physical exam of a 60-year-old adult, the nurse practitioner performs an abdominal exam. The nurse practitioner is checking the left upper quadrant of the abdomen. During percussion, an area of dullness is noted beneath the lower left ribcage. Which of the following is a true statement regarding the spleen?
The spleen is not palpable in the majority of healthy adults
Thrombocytopenia
Thrombocytopenia is defined as a platelet count of less than 150,000/μL. Symptoms usually do not show until the platelet count is less than 100,000/μL. Look for easy bruising (ecchymosis, petechilae), bleeding gums, spontaneous nosebleeds, hematuria, etc. Normal platelet count: Range is from 150,000-450,000/μL.
The nurse practitioner is reviewing the laboratory results of an adult male. Which three laboratory results are abnormal for this patient?
Thyroid-stimulating hormone 2.3 milliunits/L Thyroid-stimulating hormone (TSH) levels are used to identify hyper and hypothyroidism. TSH levels should be between 0.4 and 4.0. Hemoglobin A1c 5.4% Hemoglobin A1c evaluates the average amount of glucose in the blood over the past 2-3 months, and the normal range is between 4% and 5.6%. Hemoglobin 12.2 g/dL**** Normal hemoglobin values can vary according to age and sex. For an adult male, the level should be 13.5-17.5 g/dL, and anemia is diagnosed when the level is less than 13.5 g/dL. Low-density lipoprotein 142 mg/dL**** A high level of low-density lipoprotein (LDL) leads to a buildup of cholesterol in the arteries. While levels of 100-129 mg/dL may be acceptable for people with no cardiovascular risks, LDL should ideally be less than 100 mg/dL. Ferritin 8 ng/mL**** Ferritin level most accurately measures total iron stores in the body and the normal values for an adult male range from 12 to 300 nanograms per milliliter of blood (ng/mL).
Which of the following findings is associated with B12 deficiency anemia
Tingling and numbness of both feet Vitamin B12 deficiency anemia can cause nerve cell damage if not treated. Symptoms of B12 deficiency anemia may include tingling or numbness in fingers and toes, difficulty walking, mood changes or depression, memory loss, disorientation, and dementia.
A child born at full-term, with no complications, is at greatest risk for developing iron deficiency anemia (IDA) during which age range?
Toddler;12-36 months of age Approximately 3-7% of children at 1 year of age suffer from iron deficiency anemia. The American Academy of Pediatrics recommends routine screening for iron deficiency anemia at 12 months of age. Poor iron intake and increased consumption of cow's milk are contributing factors.
An adult patient presents to the clinic with iron deficiency anemia. The serum iron level is low. Which three other laboratory results may also be lower than normal?
Total iron-binding capacity Absolute reticulocyte count**** Red cell distribution width Mean corpuscular volume**** Hemoglobin****
Thalassemia Minor/classic case
Vast majority of individuals are asymptomatic. Discovered incidentally because of abnormal CBC results, which reveal microcytic and hypochromic RBCs. Total RBC count may be mildly elevated. Ethnic background is either Mediterranean or Asian.
Pernicious anemia results in:
Vitamin B12-deficiency anemia Macrocytic/megaloblastic normochromic anemia Neurologic symptoms
Leukemia
cancer of white blood cells
Lymphoma staging 1
disease localized to single lymph node or group
Only vitamin B12-deficiency anemia
has neurologic symptoms (tingling, numbness)
Pernicious anemia results
in vitamin B12 deficiency.
Thalassemia
inherited defect in ability to produce hemoglobin, leading to hypochromic anemia
Hemochomatosis lab/Dx
iron panel
Lymphoma stage 4
liver or bone marrow involvement
Lymphoma stage 3
lymph nodes or spleen involved; occurs on both sides of diaphragm
Pernicious anemia
macrocytic anemia.
iron deficiency anemia
microcytic, hypochromic anemia
pernicious anemia s/s
pallor, tachycardia, and sore red tongue
Lymphoma management
radiation chemo sometimes bone marrow transplant allupurinol to reduce tumor lysis syndrome
Any patient complaining of neuropathy or who has dementia
should have vitamin B12 levels checked.
If patient has anemia with MCV 76,
the next step is to order TIBC, ferritin, serum iron. If ferritin/iron levels are low, patient has iron deficiency, but if these tests are normal, patient probably has thallassemia trait.
Lymphoma Stage 2
· >1 group of LNs · on same side of diaphragm
