Patho chap 27
13. A client with a diagnosis of atrophic gastritis and consequent pernicious anemia is receiving high oral doses of vitamin B12. Which of the following changes would be most likely expected by his care provider at the completion of his treatment? A) Decreased mean corpuscular volume B) Increased serum bilirubin C) Increased folic acid levels D) Decreased free heme levels
A Feedback: Increased red cell size is associated with vitamin B12 deficiency, and MCV would decrease with treatment. Increased bilirubin and folic acid levels would not be associated with resolution of pernicious anemia, and heme is not normally present or measured in a free circulatory form.
15. Which of the following patients would be most likely to be experiencing an increase in renal erythropoietin production? A) A 71-year-old smoker admitted to hospital with exacerbation of his chronic obstructive pulmonary disease (COPD) B) A 70-year-old woman admitted with dehydration secondary to an overdose of her potassium-wasting diuretic C) A 68-year-old man with a long-standing diagnosis of polycythemia vera D) A 21-year-old man with acute blood loss secondary to a motor vehicle accident 3 hours prior
A Feedback: Increases in erythropoietin production are associated with secondary polycythemia, and not polycythemia vera, a health problem that can be induced by the hypoxia resulting from smoking and lung disease. Dehydration is associated with relative polycythemia, and sudden blood loss would not manifest in increased erythropoietin production.
14. Two years after chemotherapy and radiation therapy for lung cancer, a 72-year-old patient notices that he seems to be extremely tired all the time. The physician suspects the patient may have developed aplastic anemia. The nurse assessing the patient will likely find which of the following clinical manifestations of aplastic anemia? Select all that apply. A) Complaints of weakness and fatigue B) Small spots of skin hemorrhages over the entire body C) Excess bleeding from gums and nose D) Spoon-shaped deformity of the fingernails E) Hemolysis from renal dialysis treatments.
A, B, C Feedback: The onset of aplastic anemia may be insidious or sudden. The initial presenting symptoms include weakness, fatigue, and pallor caused by the anemia. Petechiae and ecchymoses often occur on the skin, and bleeding from the nose, gums, vagina, or GI tract may occur due to decreased platelet levels. Spoon-shaped deformity of the fingernails is seen in iron deficiency anemia. Hemolysis and blood loss from renal dialysis treatments contribute to anemia associated with a deficiency of erythropoietin (which is normally produced in the kidneys).
18. Which of the following nursing interventions would be a priority when caring for a newborn who is receiving phototherapy for high bilirubin levels? Select all that apply. A) Frequent monitoring of temperature B) Keeping diapers dry and clean C) Maintaining oral intake to prevent dehydration D) Putting lotion on his skin frequently to prevent drying/cracking of skin E) Applying sunscreen to prevent ultraviolet radiation
A, C Feedback: Effective treatment depends on the area of skin exposed and the infant's ability to metabolize and excrete bilirubin. Frequent monitoring of bilirubin levels, body temperature, and hydration is critical to the infant's care. Diapers are usually not worn when under phototherapy light (want to keep the skin exposed to the light). Applying lotion and sunscreen would result in possible burning of the infant's skin while under the light.
10. A 13-year-old African American boy comes to the ER complaining of fatigue and a rapid heartbeat. In conversation with the father, it becomes apparent to you that the boy has grown 2 inches in the previous 5 months. What is the first problem the health care team would attempt to rule out? A) Sickle cell anemia B) Iron deficiency anemia C) Thalassemia D) Aplastic anemia
B Feedback: Although each of the above answers is associated with fatigue and rapid heartbeat, male adolescents are particularly susceptible to iron deficiency anemia. They have high iron requirements because of growth spurts and dietary deficiencies.
1. A surgeon is explaining to the parents of a 6-year-old boy the rationale for the suggestion of removing the boy's spleen. Which of the following teaching points would be most accurate? A) "Ferritin is the activated and usable form of iron that your red blood cells can use to transport oxygen." B) "Ferritin is a stored form of iron that indirectly shows me whether you would benefit from iron pills." C) "Ferritin is a protein-iron complex that allows your red blood cells to make use of the iron that you consume in your diet." D) "Ferritin is the form of iron that is transported in your blood plasma to red blood cells that need it."
B Feedback: Ferritin is the protein-iron complex that is stored in tissues, especially the liver, and the serum levels can be used as an indicator of the need for iron supplements. It is not accurately characterized as an activated form of iron, nor does it mediate the actual use of iron by erythrocytes. Transferrin, not ferritin, is transported in plasma, and it is associated with iron storage.
20. The family members of an elderly patient are wondering why his "blood counts" are not rising after his last GI bleed. They state, "He has always bounced back after one of these episodes, but this time it isn't happening. Do you know why?" The nurse will respond based on which of the following pathophysiological principles? A) "Everything slows down when you get older. You just have to wait and see what happens." B) "Due to stress, the red blood cells of older adults are not replaced as promptly as younger people." C) "The doctor may start looking for another cause of his anemia, maybe cancer of the bone." D) "Don't worry about it. We can always give him more blood."
B Feedback: In older adults, the number of progenitor cells declines. During a stress situation such as bleeding, the red blood cells of older adults are not replaced as promptly as those of their younger counterparts. Given the scenario, the patient is obviously bleeding from the GI tract. There is no reason to suspect the patient has bone cancer. Answer choice D is a nontherapeutic communication technique. The nurse is trying to pacify the family and not really addressing their concern.
6. A 66-year-old female patient has presented to the emergency department because of several months of intermittently bloody stool that has recently become worse. The woman has since been diagnosed with a gastrointestinal bleed secondary to overuse of nonsteroidal anti-inflammatory drugs that she takes for her arthritis. The health care team would realize that which of the following situations is most likely to occur? A) The woman has depleted blood volume due to her ongoing blood loss. B) She will have iron deficiency anemia due to depletion of iron stores. C) The patient will be at risk for cardiovascular collapse or shock. D) She will have delayed reticulocyte release.
B Feedback: Ongoing blood loss is associated with iron deficiency anemia due to the depletion of iron stores. She is unlikely to have a depleted blood volume or be at risk for shock, situations more commonly associated with traumatic, sudden blood loss. There would not likely be a delay in the release of reticulocytes.
5. Your ESRD patient is receiving 2 units of packed red blood cells for anemia (Hgb of 8.2). Twenty minutes into the first transfusion, the nurse observes the patient has a flushed face, hives over upper body trunk, and is complaining of pain in lower back. His vital signs include pulse rate of 110 and BP drop to 95/56. What is the nurse's priority action? A) Slow the rate of the blood infusion to 50 mL/hour. B) Document the assessment as the only action. C) Discontinue the transfusion and begin an infusion of normal saline. D) Recheck the type of blood infusing with the chart documentation of patient's blood type.
C Feedback: An immediate hemolytic reaction usually is caused by ABO incompatibility. The signs include flushing of the face, urticaria (hives), headache, pain in the lumbar area, chills, fever, chest pain, tachycardia, hypotension, and dyspnea. If any of these actions occur, the transfusion should be stopped immediately. Access to a vein should be maintained because it may be necessary to infuse IV solutions to ensure diuresis. Slowing the rate of the blood infusion will not correct this hemolytic reaction and will only worsen the patient's condition. Of course, documentation after the above interventions are performed is vital. Rechecking the blood type infusing will not stop the hemolytic reaction. After corrective actions/interventions are taken, the blood bag is returned to the blood bank for further testing.
2. A 62-year-old female with a diagnosis of acute and chronic renal failure secondary to diabetes mellitus is receiving her weekly injection of epoetin, a supplementary form of erythropoietin. Which of the following statements best captures the necessity of this medication? A) Erythropoietin is needed in order for stem cells to proliferate into committed erythroid precursors. B) Erythropoietin is necessary for the accurate sensation of hypoxia that stimulates erythropoiesis. C) Erythropoietin causes the erythrocyte colony-forming units to proliferate and mature. D) Erythropoietin facilitates the extrusion of the reticulocyte nucleus and the formation of true erythrocytes.
C Feedback: Erythropoietin acts primarily in later stages of erythropoiesis to induce the erythrocyte colony-forming units to proliferate and mature through the normoblast stage into reticulocytes and mature erythrocytes. It does not act directly on the stem cells, nor does it play a role in the sensation of hypoxia. Reticulocytes already lack a cell nucleus.
8. A child has been diagnosed with thalassemia. Which of the following comorbidities may occur as a result of having thalassemia? A) Hypocoagulation B) Iron deficiency C) Splenomegaly D) Neutropeniabb
C Feedback: Thalassemia can result in enlargement of the spleen and liver due to increased hematopoiesis and red cell destruction. It is associated with thrombotic events, not hypocoagulation, as well as iron excess. Neutropenia is not associated with thalassemia.
19. If an Rh-negative mother is giving birth to an Rh-positive infant, the nurse should be prepared to administer A) antihistamines like Benadryl. B) alpha interferon. C) Rh immune globulin. D) a monoclonal antibody like infliximab.
C Feedback: The injection of Rh immune globulin prevents sensitization in Rh-negative mothers who have given birth to Rh-positive infants if administered at 28 weeks' gestation and within 72 hours of delivery, abortion, or genetic amniocentesis. Antihistamines, alpha-interferon, or infliximab is not used in this situation.
7. Amniocentesis has suggested that a couple's first child will be born with sickle cell disease. The parents are unfamiliar with the health problem, and their caregiver is explaining the complexities. Which of the following statements by the parents would suggest a need for further teaching or clarification? A) "Our baby's red cells are prone to early destruction because of his or her weak membranes." B) "Not all of his or her red cells will be sickled, but low oxygen levels can cause them to become so." C) "Sickled cells can block his or her blood vessels, especially in the abdomen, chest, and bones." D) "Our son or daughter likely won't show the effects of sickling until he or she is school-aged because of the different hemoglobin in babies."
D Feedback: Fetal hemoglobin in the infant is replaced by 8 or 10 weeks of age, and manifestations of sickle cell disease can begin at this time. Answer choices A, B, and C all convey the aspects of sickle cell disease.
12. A community health nurse is conducting a class on the nutritional component for new mothers. Which of the following teaching points would be most justified? A) "Iron supplementation is not necessary provided you are breast-feeding your infant." B) "Be aware that cow's milk depletes your baby's supply of iron." C) "Your infant needs the same amount of iron as you but has far fewer sources for obtaining it." D) "If you choose to feed your baby with formula, ensure that it is iron fortified."
D Feedback: Formula and cereals for infants should be iron fortified to preclude iron deficiency anemia. Breast-feeding does not necessarily mitigate the need for iron supplementation, and cow's milk does not deplete existing iron stores but fails to provide sufficient levels of absorbable iron. Infants and children have significantly higher iron needs than do adults.
3. A client with a diagnosis of hemolytic anemia has gone to a community-based laboratory for follow-up blood work. The lab technician confirms with the client that hematocrit is one of the components of the blood work. The client replies, "I thought the point of the blood work was to see how many red blood cells I have today." How could the technician best respond to the client's statement? A) "This result will tell your care provider about the number of red blood cells in a given quantity of your blood plasma." B) "Your hematocrit measures the average size of your red blood cells and indirectly measures your oxygen-carrying capacity." C) "The result will indicate how many of your red blood cells are new and young and will indicate your body's production rate of red cells." D) "The hematocrit measures the mass that your red blood cells account for in a quantity of your blood."
D Feedback: Hematocrit measures the mass of erythrocytes in a given quantity of blood plasma. It does not measure the number of red cells, their size, or their production rate and age.
17. A new mother and father are upset that their 2-day-old infant is requiring phototherapy for hyperbilirubinemia. The pediatrician who has followed the infant since birth is explaining the multiplicity of factors that can contribute to high serum bilirubin levels in neonates. Which of the following factors would the physician be most likely to rule out as a contributor? A) The fact that the infant is being breast-fed B) Hypoxia C) Hepatic immaturity of the infant D) Transitioning of hemoglobin F (HbF) to hemoglobin A (HbA)
D Feedback: Hemoglobin transition from HbF to HbA is not associated with hyperbilirubinemia. Breast-feeding, hypoxia, and immaturity of the young liver can contribute to hyperbilirubinemia.
11. A 22-year-old female who adheres to a vegan diet has been diagnosed with iron deficiency anemia. Which of the following components of her diagnostic blood work would be most likely to necessitate further investigation? A) Decreased mean corpuscular volume (MCV) B) Decreased hemoglobin and hematocrit C) Microcytic, hypochromic red cells D) Decreased erythropoietin levels
D Feedback: It would be unusual to note decreased levels of erythropoietin concurrent with a diagnosis of anemia. Decreased MCV, hematocrit, and hemoglobin are congruent with the diagnosis, as are microcytic, hypochromic erythrocytes.
9. A patient has been diagnosed with anemia. The physician suspects an immune hemolytic anemia and orders a Coombs test. The patient asks the nurse what this test will tell the doctor. The nurse replies, A) "They will wash your RBCs and then mix the cells with a reagent to see if they clump together." B) "They will look at your RBCs under a microscope to see if they have an irregular shape (poikilocytosis)." C) "They will be looking to see if you have enough ferritin in your blood." D) "They are looking for the presence of antibody or complement on the surface of the RBC."
D Feedback: The Coombs test is used to diagnose immune hemolytic anemias. It detects the presence of antibody or complement on the surface of the red cell. Answer choice A refers to direct antiglobulin test (DAT). Answer choice B refers to blood smear test. Answer choice C refers to iron stores test.
4. A client with a gastrointestinal bleed secondary to alcohol abuse and a hemoglobin level of 5.8 g/dL has been ordered a transfusion of packed red blood cells. The client possesses type B antibodies but lacks type D antigens on his red cells. Transfusion of which of the following blood types would be least likely to produce a transfusion reaction? A) B- B) B+ C) A+ D) A-
D Feedback: The client's blood type is A- and would necessitate A- or O- donor blood. Other types would induce a transfusion reaction.
16. 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. What will be the primary goal of his treatment? A) To control his hypertension B) To increase the amount of oxygen distributed by his red blood cells C) To reduce the mean size of his red cells D) To reduce the viscosity of his blood
D Feedback: 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.
